Coagulopathy in severe closed head injury: is empiric therapy warranted?

Closed head injuries account for a significant portion of the morbidity and mortality following blunt trauma. Severe closed head injuries can be complicated by the development of a coagulopathy that may worsen blood loss and delay invasive neurosurgical procedures. Awaiting the results of coagulation studies prior to initiating treatment of such a coagulopathy introduces an inherent delay that may allow worsening of the coagulation disturbance and negatively influence outcome. This study was undertaken to see if a subgroup of patients with severe closed head injuries had a high probability of developing a coagulopathy and would warrant empiric treatment with fresh frozen plasma. The records of adult patients admitted to our trauma center with a Glasgow coma score (GCS) of < or = 8 and an extracranial abbreviated injury score of < or = 2 during a 9-month period were reviewed. Patients with penetrating trauma or whose altered level of consciousness was due to sedation or shock were excluded. The presence of coagulation abnormalities was determined according to prothrombin time and partial thromboplastin time obtained on admission. The time to invasive neurosurgical procedures for both coagulopathic and noncoagulopathic patients was determined as well as the mean number of hospital days, intensive care unit days, and the mortality for each group. Eighty-one per cent of the patients with a GCS < or = 6 were coagulopathic on admission, and all patients with a GCS of 3 or 4 were coagulopathic. In contrast, no patient with a score of 7 or 8 was coagulopathic. The coagulopathic patients tended to have a higher mortality than the noncoagulopathic patients (53 versus 22%) as well as longer intensive care unit and hospital stays. The mean time to neurosurgical intervention for the coagulopathic group was 226.0 +/- 190.9 minutes versus 84.8 +/- 38.4 minutes for the noncoagulopathic patients. We conclude that patients with closed head injuries who present with a GCS of 6 or less are candidates for empiric treatment for coagulopathy. Such treatment will negate the delay of awaiting coagulation studies. Whether or not such therapy shortens the interval between admission and neurosurgical procedures or alters outcome will require prospective study.