急诊重症创伤患者凝血功能与疾病程度及预后的相关性分析

Correlation analysis of coagulation function,disease severity and prognosis in emergency patients with severe trauma

目的分析急诊重症创伤患者凝血功能与疾病程度及预后的相关性。方法回顾性分析武汉市三医院光谷院区急诊科2018年7月—2020年8月收治的101例重症创伤患者,根据患者进入ICU后14d内的预后情况将患者分为死亡组(19例)和存活组(82例),根据损伤严重度评分(ISS)将患者分为危重组(17分≤ISS≤25分,61例)和极危重组(ISS>25分,40例)。患者入院后,于输血及纠正凝血功能障碍前,采用生化分析仪检测患者血浆中血小板计数(PLT)、D-二聚体(DD)水平,全自动凝血分析仪检测凝血酶原时间(PT)、部分活化凝血酶原时间(APTT)、纤维蛋白原浓度(FIB)。比较不同创伤严重度、不同预后患者一般资料和凝血功能指标,多因素Logistic回归分析患者凝血功能指标与创伤严重度和预后的关系。结果极危重组血浆PLT、FIB水平为(52.58±7.25)×109/L、(2.01±0.62)g/L,低于危重组的(161.25±18.32)×109/L、(3.24±0.58)g/L(P<0.05);极危重组失血量>2 000mL患者比例50%、ISS(29.4±6.1)分、急性生理学与慢性健康状况评分(APACHEⅡ评分)(21.9±8.5)分、血浆DD水平(22.12±3.25) mg/L、PT(23.25±2.14) s、APTT(41.25±4.58)s,高于危重组的23%、(23.0±6.6)分、(14.5±5.7)分、(7.85±1.04)mg/L、(16.68±1.55)s、(38.57±4.56)s(P<0.05);多因素Logistic分析结果显示ISS、APACHEⅡ评分、DD、PT、APTT是急诊重症创伤患者病情加重的独立危险因素(OR=3.255,1.598,1.655,4.927,2.224)。死亡组血浆PLT、FIB水平(64.58±6.67)×109/L、(2.14±0.52)g/L,低于存活组的(189.43±25.79)×109/L、(4.55±0.77)g/L(P<0.05);死亡组年龄(58.0±7.6)岁、失血量>2 000mL患者比例63%、ISS(31.8±8.1)分、APACHEⅡ评分(21.2±11.5)分、血浆DD水平(18.59±2.29)mg/L、PT(24.56±2.64)s、APTT(54.33±4.97)s,高于存活组的(49.2±6.4)岁、27%、(24.1±6.0)分、(16.6±5.7)分、(4.24±0.69)mg/L、(14.37±1.98)s、(29.69±3.46)s,P<0.05;失血量、ISS、APACHEⅡ评分、DD、PT、APTT是急诊重症创伤患者预后不良的独立危险因素(OR=3.348,4.695,2.140,5.821,2.062,6.623)。结论凝血功能与急诊重症创伤患者疾病程度密切相关,凝血功能指标DD、PT、APTT是患者预后不良的独立危险因素,是评估患者预后的重要依据。

Objective To analyze the correlation between coagulation function and disease severity,prognosis in emergency patients with severe trauma.Methods A total of 101 cases of severe trauma admitted to the Department of Emergency,Guanggu Hospital District,Third Hospital of Wuhan from Jul.2018 to Aug.2020 were retrospectively analyzed.According to their prognosis within 14 days after entering the intensive care unit (ICU),the patients were divided into the death group (19 cases) and the survival group (82 cases).According to injury severity score (ISS),the patients were divided into critical group (17 points≤ISS≤25 points,61 cases) and extremely critical group (ISS>25 points,40 cases).The biochemical analyzer was used to detect the level of platelet count (PLT)and D-dimer (DD) in the plasma,and the automatic coagulation analyzer was used to detect prothrombin time(PT),activated partial thromboplastin time (APTT),fibrinogen concentration (FIB).The general clinical data and coagulation function indexes of patients with different trauma severity and different prognosis were compared,and the relationship between the coagulation function indexes of patients and the trauma severity and prognosis was analyzed by multivariate logistic regression.Results The plasma PLT and FIB levels in extremely critical group were (52.58±7.25)×109/L,(2.01±0.62) g/L,which were lower than those in the critical group (161.25±18.32)×109/L,(3.24±0.58) g/L (P<0.05).The ratio of blood loss>2000mL was 50.00%,ISS was (29.4±6.1) points,APACHA-Ⅱscore was (21.9±8.5) points,plasma DD level was (22.12±3.25) mg/L,PT was (23.25±2.14) s and APTT was (41.25±4.58) s in extremely critical group,which were higher than those in the critical group[23%,(23.0±6.6)points,(14.5±5.7)points,(7.85±1.04)mg/L,(16.68±1.55)s,(38.57±4.56)s](P<0.05).Multiple factors logistic analysis results showed that the ISS,APACHEⅡscore,DD,PT,APTT were independent risk factors for the poor prognosis of emergency severe trauma patients (OR=3.255,1.598,1.655,4.927,2.224).Plasma PLT and FIB levels in the death group were (64.58±6.67)×109/L,(2.14±0.52) g/L,lower than those in the survival group(189.43±25.79)×109/L,(4.55±0.77) g/L (P<0.05).In the death group,age was (57.98±7.62) years old,the proportion of patients with blood loss>2000mL was 63%,ISS score was (31.77±8.10)poins,APACHEⅡscore was(21.2±11.5)poins,and plasma DD level was (18.59±2.29) mg/L,PT (24.56±2.64) s,APTT (54.33±4.97) s,higher than those of the survival group[(49.24±6.35) years,27%,(24.1±6.0)poins,(16.6±5.7)poins,(4.24±0.69) mg/L,(14.37±1.98) s,(29.69±3.46) s],P<0.05.Blood loss volume,ISS score,APACHEⅡscore,DD,PT,and APTT were independent risk factors for poor prognosis of emergency severe trauma patients (OR=3.348,4.695,2.140,5.821,2.062,6.623).Conclusion Patients with severe trauma in emergency department are more likely to have coagulation dysfunction.The coagulation function indexes of DD,PT and APTT are independent risk factors for poor prognosis of patients and are important basis for evaluating the prognosis of patients.