急性重症创伤患者凝血功能异常的临床意义

Clinical significance of blood coagulation and fibrinolysin in acute severe trauma patients

目的 观察急性重症创伤患者凝血功能障碍与病情严重度及预后的关系.方法 回顾性分析本院急救部2012年1月～ 2014年1月收治的创伤患者,所有患者均给予急性生理及慢性健康状况（A-PACHEⅡ）评分＞6分,最终符合条件达61例.对所有入选的患者进行损伤严重度评分（ISS）,根据得分情况分为：非危重组（ISS≤16）、危重组（16＜ ISS≤25）、极危重组（ISS＞ 25分）;根据预后分为存活组和死亡组.检测患者伤后24h内血小板计数（PLT）、纤维蛋白原（FIB）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、D二聚体（D-dimer）、血栓弹力图各指标（R值、K值、α角度、MA值）.比较不同严重程度、不同预后患者凝血功能、血栓弹力图指标的变化特点、差异及相关性.结果 极危重组与其他两组比较,PLT、FIB明显下降,D二聚体明显升高,PT明显延长,P＜0.05,差异有统计学意义.死亡组与存活组比较,PLT明显下降,D二聚体明显升高,APTT、PT均明显延长,P＜0.05,差异有统计学意义.极危重组与其它两组比较,R值与K值均明显增大,MA值与α角度明显减小,P＜0.05,差异有统计学意义.存活组与死亡组比较,R值与K值明显增大,MA值与α角度明显减小,P＜0.05,差异有统计学意义.R值与APTT、TT呈正相关;MA值与PLT、FIB呈正相关,与APTT、PT、TT呈负相关;α角度与PLT呈正相关,与PT、TT呈负相关;K值与PLT呈负相关,与DD、PT、TT呈正相关.结论 重症创伤患者普遍合并凝血功能紊乱,其程度与病情严重度及预后呈明显的相关性.监测其凝血指标及血栓弹力图对判断患者的预后及评估病情严重程度有重要意义,为临床救治提供依据.

Objective To analyze and study the relationship between coagulation disorders and severity and prognosis in patients with severe trauma.Methods Totally 61 cases were divided into non severe group（ISS≤16）,the risk group（16 ＜ ISS ≤25） and the high risk group （ISS ＞ 25） according to injury severity score （ISS） and survival group and death group according to prognosis.The levels of plasma platelet count（PLT）,fibrinogen（FIB）,prothrombin time（PT）,activated partial thromboplastin time （APTT）,D-dimer （DD）,R （reaction time）,K （clot formation time）,Angle and MA （maximum amplitude）were detected.The abnormal levels of the coagulant index in 24 hours were compared in different groups.Results Compared with the other two groups,PLT and FIB in the high risk group were significantly lower while DD and PT were significantly higher（P ＜ 0.01）.Compared with the survival group,PLT in the death group was significantly lower while DD,APTT and PT were significantly higher（P ＜ 0.05）.Compared with the non-severe group and the risk group,R and K were significantly higher while MA and Angle were significantly lower in the high risk group（P ＜ 0.05）.Compared with the survival group,R and K were significantly higher while MA and Angle were significantly lower in the death group.According to the relevance analysis,there was positive correlation between R and APTT and PT.There was positive correlation between MA and PLT,FIB,but negative correlation between MA and APTT,PT and TT.There was positive correlation between Angle and PLT,but negative correlation between Angle and PT,TT.There was negative correlation between K and PLT,but positive correlation between K and DD,PT and TT（P ＜ 0.05）.Conclusion There are universal coagulation disorders in patients with acute severe trauma.The degree of coagulation disorders is associated with severity and prognosis.Thromboelastography is good for evaluating the coagulation function.Meanwhile,the results of standard coagulopathy tests and thromboelastography detection are significant for evaluating severity and prognosis in the severe trauma patient.