Early thrombocytopenia at hospital admission predicts mortality in patients with non-isolated severe traumatic brain injury

Early thrombocytopenia at hospital admission predicts mortality in patients with non-isolated severe traumatic brain injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Early thrombocytopenia at hospital admission predicts mortality in patients with non-isolated severe traumatic brain injury Patricia Piñeiro, Alberto Calvo, Maria Dolores Perez-Díaz, Silvia Ramos, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4697908/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Patients with severe traumatic brain injury (STBI) often experience an abnormal hemostasis that contributes to mortality and unfavorable neurological outcomes. We aimed to analyze epidemiologic, clinical and laboratory factors associated with mortality in patients with severe traumatic brain injury during the first 48 hours after in-hospital admission. Methods We performed an observational retrospective study of STBI patients with associated extracranial trauma [defined as Injury Severity Score (ISS) ≥ 16 with an Abbreviated Injury Scale ( AIS) head and neck ≥ 3 and Glasgow Coma Scale (GCS) ≤ 8], admitted to a Level II trauma center over 7 years (2015–2021). Patients were divided in 2 groups: survivors and dead. We assessed differences regarding demographics, trauma severity, hemodynamics, disability, need of surgery, length of stay, transfusions, need of massive transfusion protocol and hemostatic laboratory parameters at different time points. Results 134 STBI patients were included. Patients who died were older, mostly men and showed higher trauma severity and disability. Hemoglobin, platelets and clotting parameters deteriorated after admission to the emergency department (ED) with significant differences between groups within the first 24h after admission. Platelet count < 150 × 10 3 /µL at ED arrival, Glasgow coma scale and age were independent risk factors for mortality. Conclusions Older age, Glasgow coma scale and platelet count at ED arrival were independent risk factors for mortality in STBI patients with associated extracranial trauma. Early thrombocytopenia < 150 × 10 3 /µL at ED arrival may be used as a simple prognostic tool to early predict mortality between non-isolated STBI. Health sciences/Neurology Health sciences/Diseases/Trauma Traumatic brain injury intracranial hemorrhage coagulopathy thrombocytopenia mortality emergency department. Figures Figure 1 Figure 2 Introduction Severe traumatic brain injury (STBI) is one of the main causes of death and disability throughout the world, yet associated neurological morbidity and mortality have not decreased significantly during the last 30 years [ 1 ]. Prognosis of patients with STBI is still uncertain, and multiple studies try to identify predictors of outcome in these patients. Patients with STBI often have intracranial bleeding which can be accompanied by secondary injury. This secondary injury may consist of brain swelling and progression of hemorrhagic injury (PHI) which, ultimately, could form a risk of herniation and death [ 2 ]. In addition, STBI patients who suffer a traumatic intracranial hemorrhage remained at risk for developing a coagulopathy after trauma. After STBI, hemostasis is often derailed, leading to a hypocoagulopathic and—less often—a hypercoagulopathic state [ 3 ] depending on injury pattern, presence of hypoperfusion, endothelial damage, hemostatic treatment, individual responses, genetic predisposition, and comorbidities [ 4 ]. The presence of coagulopathy is a well-recognized predictor of poor outcomes in patients with STBI, being associated with increased rates of disability and mortality due to the increased risk of PHI and brain edema progression [ 3 , 5 , 6 ]. Coagulopathy is usually defined as low platelet count or elevated international normalized ratio (INR), prothrombin time (PT) or activated partial thromboplastin time (APTT) [ 7 ]. However, the incidence and the degree to which a specific coagulopathy of STBI contributes to the overall burden of TBI mortality remains unclear, although platelet count and dysfunction and coagulopathy appear to be relevant factors in isolated STBI [ 3 , 8 , 9 ]. In addition, STBI patients with associated extracranial trauma are difficult to diagnose and manage, and may associate more hypotension and coagulopathy resulting from extracranial injuries, which further darkens the prognosis compared to isolated STBI [ 10 ]. On this basis, there is a lack of insight into STBI-associated coagulopathy that clearly contrasts with their potential clinical consequences. Therefore, we aimed to study the influence of hemostatic abnormalities evaluated at the emergency department (ED) and hemostasis during the first 48 hours after STBI to further determine whether dead non-isolated STBI patients show a different hemostatic admission profile compared to non-isolated STBI survivors. Secondly, we also investigate whether other epidemiological and clinical characteristics were associated with increased risk of mortality in these patients. In that case, STBI patients with associated extracranial trauma patients should be better characterized, and we could potentially implement earlier strategies to improve clinical outcomes. Patients and Methods We performed an observational descriptive retrospective study in a Level II equivalent trauma center (Gregorio Marañón Universitary General Hospital) between 2015–2021 years. This study follows [ 11 ]. The study was approved by the research ethical committee of our institution (Drug Research Ethics committee of Gregorio Marañón Universitary General Hospital). All research was performed in accordance the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for retrospective cohort studies and with the Declaration of Helsinki. Due to its retrospective nature, informed consent was waived by our research ethical committee regulations. Patients were recruited from our local trauma registry. Inclusion criteria were patients with non-isolated severe TBI [defined as Injury Severity Score (ISS) ≥ 16 with an Abbreviated Injury Scale ( AIS) head and neck ≥ 3 and Glasgow Coma Scale (GCS) ≤ 8], ≥ 18 years old, admitted within 6 hours of injury to our center. We excluded patients who were taking antiplatelet and or anticoagulant medication, pregnant women, as well as those with liver disease, chronic kidney disease on hemodialysis, chronic alcoholic or previous hemostatic disease as well as patients with diffuse axonal injury due its due to their possible role on hemostatic and neurological disturbances. During the study period a total of 151 STBI patients were admitted to our center. After excluding 17 patients, 134 patients composed the study group. Patients included were further analyzed in two subgroups: survivors (83) and dead (51) (Fig. 1 ). Data collection All patients were initially admitted to the ED for the initial assistance. Afterwards, they were transferred to the radiology or operating room depending on their clinical stability. On admission, all patients were clinically evaluated by a neurosurgeon and underwent a head computed tomography (CT) scan, except when extracranial surgery was necessary for immediate damage control, when the head computed tomography scan was performed at the end of surgery. All evaluations of CT scans were extracted from the original report by the radiologist. Acute brain injuries assessed by CT imaging included the following: epidural hematoma (EDH), subdural hematoma (SDH), subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH) and skull fracture. Volumes of EDH, SDH, and parenchymal/hemorrhagic contusions were measured. In addition, status of the ambient cisterns and the presence of midline shift were assessed. The indication for neurosurgery was established by the neurosurgery staff in accordance with the recommendations established by the international guidelines for the surgical management of TBI [ 12 ]. In general, the surgical criteria were based on the level of consciousness, neurological focality, hematoma volume and/or thickness, presence of signs of cisternal compression, deviation of the midline > 5 mm or maintained (> 1 hour) refractory intracranial pressure (> 25 mmHg). After radiological study and/or surgery patients were admitted to the surgical intensive care unit (SICU). The cause of death was obtained from the death report of the chart. Brain death was defined as irreversible cessation of vital activity of the whole brain (including the brainstem), verified by well-defined neurological clinical protocols and specialized tests (radiographic test and/or electroencephalogram) following international guidelines [ 13 ]. In addition, devastating brain injury was defined as any neurological condition assessed at the time of hospital admission, which represented an immediate threat to life or incompatible with good functional recovery, and where early limitation or withdrawal of therapy was considered [ 14 ]. Different epidemiological and clinical data were compared between groups: age, sex, time to hospital admission, cause of accident, pre-hospital fluid replacement, hemodynamics (heart rate and arterial blood pressure), neurologic parameters [GCS at admission, Glasgow Outcome Score (GOS) at discharge], trauma severity (ISS, AIS, AIS head and neck), length of stay in SICU, red blood cells (RBC) transfusions, need of massive transfusion protocol (MTP), need of urgent surgery and neurosurgery, and associated extracranial injury. MTP was activated when Assessment of Blood Consumption (ABC) score was ≥ 2. Laboratory blood tests were collected by arterial samples at different standardized times as part of our routine patient care: arrival to ED, admission to SICU, 24h after SICU admission, 48h after SICU admission. Blood samples were taken to determine INR, PT and APTT, as well as values for fibrinogen, hemoglobin, and platelets, on arrival to the emergency department, admission to the SICU, and at 24 hours and 48 hours after admission to the SICU. Thrombocytopenia was defined as a platelet count less than 150 x 10 3 /µL based on most extended threshold in the literature [ 15 ]. Data availability All data generated or analyzed during this study are included in this published article. The database is available from the corresponding author. Statistical Analysis Statistical analysis was performed using the IBM SPSS software package (IL, USA, version 21.0). Categorical data are expressed as percentages. Quantitative data are shown as mean (standard deviation) for normally distributed data, while non-normally distributed data are expressed as median (interquartile range). We made a univariate analysis with mortality during hospital stay. Medians for numerical variables were compared between groups for continuous data using the Mann-Whitney test, and χ 2 test or Fisher’s exact test (when appropriate) to compare categorical variables. We then performed a logistic regression analysis for mortality including variables which had a p value less than 0.1 in univariate analysis. Finally, for survival analysis according to platelet count 150 x 10 3 /µL, the Kaplan-Meier method was used and the curves were compared using the Log-Rank test. Statistical significance was set at 0.05 p-value. Results During the observation period (2015–2021), a total of 151 non-isolated STBI patients were admitted to our center. 134 patients composed the study group. Out of these 134 patients, 83 (62%) survived and 51 (38%) died. Regarding those who deceased, 45 (88%) died from neurological causes (brain death or devastating brain injury) and only 6 patients died from non-neurological causes such us hemorrhagic shock or limitation of therapy. 50% of patients died within 48 hours of admission to hospital. Demographic and clinical characteristics of these STBI are summarized in Table 1 . Patients who died were significantly older, male sex and experienced less motorcycle collisions (15.6% vs 24.1%, p = 0.011). They also significantly shown higher ISS (41 vs 34, p = 0.003) and AIS head and neck (5 vs 4, p < 0.001) while GCS (5 vs 4, p < 0.001), GOS (1 vs 3, p < 0.001), need of urgent surgery (35% vs 70%, p < 0.001) and length of stay in SICU (2 vs 17, p < 0.001) were lower comparing to STBI survivors. No statistical differences between both groups were observed regarding to time to reach hospital, pre-hospital fluid replacement, other mechanisms of accidents, hemodynamics (systolic arterial pressure, heart rate), AIS overall, massive transfusion protocol activation and RBC transfusions. Table 1 Epidemiological and clinical characteristics of non-isolated severe traumatic brain injury patients. Total (n = 134) Median (IQR) Survivors (n = 83) Median (IQR) Dead (n = 51) Median (IQR) p Age (years) 45 (29.75–65) 39 (29–55) 57 (36–78) 0.003 Male sex, n (%) 86 (64.1%) 53 (63.8%) 33 (64.7%) 0.981 Time taken to reach hospital (min) 51 (41–61) 52 (43–59) 49 (40–65) 0.508 Mechanism of trauma • Car, n (%) 13 (9.7%) 9 (10.8%) 4 (7.8%) 0.608 • Motorcycle, n (%) 28 (20.9%) 22 (26.5%) 6 (11.7%) 0.039 • Knocked down, n (%) 43 (32.1%) 25 (30.1%) 18 (35.3%) 0.454 • Fall, n (%) 50 (37.3%) 27 (32.5%) 23 (45.1%) 0.387 Pre-hospital fluid replacement (mL) 600 (300–1200) 650 (300–1275) 600 (200–1100) 0.571 Systolic arterial pressure (mm Hg) 120 (90–140) 119 (90–136) 120 (81–150) 0.916 Heart rate (bpm) 97 (79.75–120.5) 100 (82–120) 90 (79–124) 0.369 Glasgow score 6.5 (3–13) 9 (4–13) 4 (3–7) < 0.001 AIS, head and neck 4 (3–5) 4 (3–4) 5 (4–5) < 0.001 AIS, overall 10 (7–12) 9 (8–11) 10 (5–13) 0.897 ISS 34 (29–43) 34 (27–41) 41 (34–50) 0.003 Length of stay in SICU (days) 9 (3–25.25) 17 (8–32) 2 (0–5) < 0.001 Red blood cell units, n 0 (0–5) 0 (0–4) 0 (0–6.75) 0.638 MTP, n (%) 28 (20.7%) 17 (20.2%) 11 (21.6%) 0.853 GOS 3 (1–5) 3 (2–5) 1 (1–1) < 0.001 Need for urgent surgery, n (%) 77 (57%) 59 (70%) 18 (35%) < 0.001 Need of urgent neurosurgery, n (%) 36 (26.8%) 24 (28.9%) 12 (23.5%) 0,52 Categorical data are shown in sample size (n) and percentages. Quantitative data are shown as median (percentile 25-percentile 75) as no normally distributed. Abbreviations: n, number; IQR, interquartile range; min, minutes; mL, milliliters; bpm, beats per minute; AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; MTP, massive transfusion protocol; GOS: Glasgow Outcome Score. According to the radiological findings of the initial CT scan performed on admission (Table 2 ), we observed that in the dead group, most patients sustained traumatic SAH (58.8%), and SDH (56.9%), followed by cerebral contusion (27.5%) and IPH (23.5%), while in the survivors’ group, most patients experienced traumatic SAH (56%), followed by SDH (41.7%) and cerebral contusion (35.7%). Skull fractures were also common in both groups (54.9% vs 40.5%). However, significant differences were only found between the both groups in terms of IPH (23.5% vs 2.4%, p < 0.001), cerebral contusion (23.5% vs 35.7%, p = 0.03) and radiological signs of brain herniation (23.5% vs 7.1, p = 0.007). No statistical differences were observed regarding the need for urgent neurosurgery between both groups (23.5% vs 28.9%). Table 2 Neuroradiological findings in admission CT. Survivors (n = 83) n, (%) Dead (n = 51) n, (%) p SAH 47 (56%) 30 (58.8%) 0.744 SDH 35 (41.7%) 29 (56.9%) 0.086 EDH 9 (10.7%) 1 (2%) 0.06 IPH 2 (2.4%) 12 (23.5%) < 0.001 IVH 7 (8.3%) 5 (9.8%) 0.771 Cerebral contusion 30 (35.7%) 14 (27.5%) 0.034 Brainstem hemorrhage 1 (1.2%) 2 (3.9%) 0.319 Brain swelling 3 (3.6%) 7 (13.7%) 0.211 Brain herniation sings 6 (7.1%) 12 (23.5%) 0.007 Skull fracture 34 (40.5%) 28 (54.9%) 0.103 Categorical data are shown in sample size and percentages. Abbreviations: n, number; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage; EDH, epidural hemorrhage; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage. In our sample, the most frequent associated extracranial injuries in both groups (Table 3 ) were those affecting the thorax (66.42%) and skeleton (65.67%), followed in order of frequency by the spinal column (47.01%), abdomen (34.33%), pelvis (31.34%), face (30.60%), retroperitoneal space (29.73%) and liver (28.21%). Extracranial injuries were equally distributed between STBI patients who survived and STBI patients who died, except for cervical spinal cord (50.6% vs 41.2%), thorax (72.2% vs 56.8%) and liver (20.5% vs 9.8%) injuries, where more common in patients who survived. However, no statistical differences with respect to extracranial injuries were observed between survivors and non-survivors. Table 3 Associated extracranial injury of non-isolated severe traumatic brain injury patients. Total n, (%) Survivors n, (%) Dead n, (%) p Face 41 (30.60%) 23 (27.7%) 18 (35.3%) 0.335 Spine 63 (47.01%) 42 (50.6%) 21 (41.2%) 0.288 Mediastinum 9 (6.72%) 6 (7.2%) 3 (5.6%) 0.762 Thorax 89 (66.42%) 60 (72.2%) 29 (56.8%) 0.066 Abdomen 46 (34.33%) 30 (36.1%) 16 (31.3%) 0.572 Pelvic fracture 42 (31.34%) 25 (30.1%) 17 (33.3%) 0.697 Skeleton 88 (65.67%) 55 (66.2%) 33 (64.7%) 0.854 Liver 22 (28.21%) 17 (20.5%) 5 (9.8%) 0.167 Spleen 9 (13.24%) 7 (8.4%) 2 (3.9%) 0.289 Massive hemoperitoneum 1 (1.54%) 1 (1.2%) 0 (0%) 0.426 Diaphragm 1 (1.54%) 1 (1.2%) 0 (0%) 0.426 Kidney 11 (15.71%) 7 (8.4%) 4 (7.8%) 0.87 Retroperitoneal hematoma 22 (29.73%) 13 (15.6%) 9 (17.6%) 0.723 Categorical data are shown in sample size and percentages. Abbreviations: n, number. In order to study the laboratory abnormalities in hemostasis after STBI we analyze differences between survivors and dead in regard to clotting values and platelet count during the first 48 hours (Table 4 ). Within first 24 hours, INR and APTT deteriorated gradually in both groups while PT increased in patients who survived and remained stable in those who died. After 48 hours, INR, APTT and PT return to normal values. We only found significant differences regarding clotting parameters between survivors and dead STBI patients at SICU admission time, when dead patients showed prolonged INR, APTT and PT times comparing to survivors (p < 0.05). In contrast, fibrinogen levels increased exponentially at 24 hours after SICU admission in both groups, at which point there were significant differences between survivors and dead (517 vs 424, p = 0.023). Table 4 Laboratory results for clotting parameters, hemoglobin and platelet count since admission to 48 hours in the SICU. Emergency Department arrival SICU admission 24 hours at SICU 48 hours at SICU Median (IQR) p Median (IQR) p Median (IQR) p Median (IQR) p INR (s) Survivors 1.07 (1.00-1.3) 0.203 1.11 (1.02–1.28) 0.01 1.16 (1.06–1.30) 0.287 1.10 (1.02–1.22) 0.173 Dead 1.18 (1.01–1.48) 1.19 (1.08–1.54) 1.19 (1.08–1.42) 1.11 (1.04–1.43) APTT (s) Survivors 28.8 (26.5–34.4) 0.167 28.5 (26.2–32.9) 0.04 29.1 (27.4–31.1) 0.584 29.0 (27.3–31.0) 0.371 Dead 32.9 (25.8–45.6) 34.0 (26.4–43.9) 29.7 (26.3–33.7) 29.7 (26.6–33.3) PT (s) Survived 12.8 (11.8–15.5) 0.184 13.2 (12.1–15.5) 0.006 13.9 (12.6–15.6) 0.287 13.2 (12.0–14.6) 0.514 Died 14.1 (12.0–17.8) 14.3 (12.9–18.7) 14.2 (12.8–17.1) 13.2 (12.3–16.8) Fib (g/L) Survivors 12.8 (11.8–15.5) 0.184 13.2 (12.1–15.5) 0.006 13.9 (12.6–15.6) 0.287 13.2 (12.0–14.6) 0.277 Dead 14.1 (12.0–17.8) 14.3 (12.9–18.7) 14.2 (12.8–17.1) 13.2 (12.3–16.8) Hb (g/dL) Survivors 12.4 (10.5–13.8) 0.01 11.8 (10.4–13.2) 0.001 10.2 (9.2–11.6) 0.238 9.1 (8.2–10.4) 0.927 Dead 10.5 (7.8–13.2) 10.1 (8.6–12.1) 9.8 (8.7–11.3) 9.5 (8.4–10.4) PC (x 10 3 /L) Survivors 200 (159–238) < 0.001 192 (134–235) < 0.001 143 (108–176) < 0.001 124 (100–164) 0.001 Dead 149 (114–184) 130 (98–160) 107 (81–129) 92 (70–130) Quantitative data are shown as median (percentile 25-percentile 75) as no normally distributed. Abbreviations: IQR, interquartile range; pl, platelets; INR, International Normalized Ratio; APTT, activated partial prothrombin time; Fib, fibrinogen; PT, prothrombin time; Hb, hemoglobin; PC, platelet count; SICU, surgical intensive care unit. In addition, Platelet count also decreased progressively after STBI in both groups, highlighting a marked initial lower platelet count recorded in patients who eventually died. Interestingly, we found that while platelet levels remained stable among patients who survived and only began to fall after 24 hours, in patients who died, platelet levels decreased since ED arrival. In fact, platelet count was significantly lower in dead STBI patients when compared to survivors at all measured times (p < 0.001). Hemoglobin levels decreased clearly in both groups, with statistically significant lower values in dead STBI patients at ED arrival (p = 0.01) and SICU admission (p = 0.001). Furthermore, when we performed the Kaplan Meier survival curve (Fig. 2 ) for admitted patients with a platelet count less than 150 x 10 3 /µL we observed that ED admitted patients with 150 x 10 3 /µL to the ED (p < 0.01), although both curves stabilized during the first few days after STBI. Finally, the logistic regression analysis (Table 5 ) revealed that age, GCS and platelet count were at ED arrival were independently associated with an increase in mortality. Table 5 Statistical results of the logistic regression analysis for mortality B S.E. Wald df Sig. Exp(B) Age 0.037 0.011 11.352 1 0.001 1.037 Glasgow coma scale score -0.226 0.055 16.914 1 < 0.001 0.797 Platelet count on ED admission -0.01 0.003 8.976 1 0.003 0.99 Constant 1.15 0.847 1.843 1 0.175 3.159 Abbreviations: B, estimated parameter; S.E, standard error; df, degrees of freedom; sig., signification; Exp(B), B exponential. Discussion Our study investigating a sample of STBI patients with associated extracranial trauma during 7 years showed the predictive value of blood routine tests at admission and clinical characteristics for mortality outcomes, highlighting the usefulness of early assessment of platelet count and function and the need to develop treatment strategies for coagulation abnormalities in non-isolated STBI patients. In terms of clinical characteristics, STBI mortality is highly influenced by epidemiological and clinical characteristics [ 16 , 17 ]. In our cohort, patients who died were older and mostly male sex. Remarkably, the logistic regression model pointed out to age as an independent predictor of STBI-mortality, in accordance with the literature [ 17 , 18 ]. This higher risk of mortality in older STBI patients might be explained due to their poor cardiovascular reserve in response to the stress generated by trauma, attenuation of cerebral autoregulation mechanisms, less tolerance to cerebral ischemia, comorbidities or greater postoperative complications in case of urgent surgery [ 19 ]. Likewise, males usually show higher mortality rates among the series [ 20 ] because the number of males included in TBI studies is higher than female due to their increased probability of injury (motor vehicle collisions, sports and suicides) [ 21 ]. Our study also revealed a lower incidence of death in motorcycle collisions, owing to the additional protection of wearing helmet [ 22 ]. Assessment of overall injury severity is considered of fundamental importance in the clinical outcome of patients who suffer STBI with extracranial trauma. In our sample, non-survivor STBI showed a higher ISS and head and neck AIS scores, lower GCS and GOS, as compared to survivors. These findings are consistent with previous studies which correlate higher AIS and ISS as well as lower GCS with worse neurological prognosis (GOS score) ant STBI mortality [ 22 , 23 ]. We did not confirm the ability of all these scores to predict the prognosis of STBI patients in a logistic regression model. In contrast, our study confirmed that only age and admission GCS score can be used as independent predictors of mortality in STBI patients with extracranial trauma, as previous evidence has correlated it [ 23 , 24 ]. In addition to clinical features, cranial CT scans play an important role in the diagnosis and prognosis of STBI. The most common CT findings in both groups were traumatic SAH (58.8%) and SDH (56.9%) followed by cerebral contusion (27.5%). Notably, non-survivors had more IPH, swelling and radiological signs of brain herniation comparing to survivors, in which cerebral contusion was more frequent. For this reason, due to the similar proportion of surgically treatable lesions in both groups, as well as the presence of a higher number of initial poor prognosis lesions that discourage surgical treatment in the dead group, no differences were found in the number of urgent neurosurgeries between groups. In this regard, previous studies have demonstrated that some initial CT findings such as signs of brain shift and intraparenchymal hemorrhage are more likely to have PHI [ 25 ], coagulopathy and mortality [ 26 , 27 ]. Patients who sustained a traumatic intracranial hemorrhage and/or increased ICP at admission CT scan remain at risk for developing a coagulopathy until 72 h after trauma, showing worse clinical outcomes than patients who do not develop a coagulopathy [ 6 ]. Coagulation disorders in TBI are complex and are characterized by consumption of clotting factors and platelets, platelet dysfunction, and hyperfibrinolysis [ 28 ]. Although coagulation abnormalities have been studied previously in the isolated TBI population [ 6 , 29 ] this is one of the few reports showing the occurrence of a coagulopathy in STBI patients who present traumatic intracranial hemorrhage with associated extracranial injuries. Diagnostic criteria for coagulopathy are inconsistent in the literature, but it may be recognized by conventional lab tests [ 30 ]. In our study, we observed that clotting parameters, platelets, and hemoglobin deteriorated gradually from admission until 48 hours, with significant differences between groups depending on the measured time. We only found statistical differences between survivors and dead regarding PT, INR and APTT at admission to the SICU. This abnormalities between ED arrival and SICU admission might be explained because lab test at SICU admission are usually done some hours after the injury and ED arrival, reflecting that hemostatic function changes over time as compensatory mechanisms are engaged and inflammation progresses [ 31 ]. Different previous studies have shown inconsistent results regarding conventional clotting test. The incidence of an elevated PT, INR or APTT in TBI varies widely, from 1–31% [ 32 ], mostly affected by testing time and injury severity. In a recent systematic review, Fletcher-Sandersjöö [ 29 ] found that most of studies noted that TBI was followed by a decrease in markers of coagulation cascade function. Furthermore, not all patients with abnormalities in laboratory coagulation tests are bleeding [ 9 ]. In fact, Juratli and coworkers [ 33 ] found no significant difference in relation to an elongated INR or APTT and PHI. Thus, PT, INR or APTT have not been proved to be a risk factor or an exclusive indicator of PHI [ 30 ]. We found that the platelets count at ED admission was the only significant blood parameter in multivariate logistic regression model, apart from age and GCS score. In our study, platelet levels significantly decreased in both groups after STBI, highlighting a lower platelet count since arrival to ED in patients who eventually died. This decrease in platelet count appeared to be independent of other hemostatic disorders (liver insufficiency, alcohol consumption, etc.) and antithrombic therapy. Our results are consistent with Carrick’s report [ 34 ], who found that patients with moderate and STBI are at risk of developing progressive thrombocytopenia after admission. Besides platelet count, platelet dysfunction has been shown to be present after TBI, contributing also to hemorrhagic complications [ 35 ]. We were not able to measure platelet function, but it is assumed that decreased platelet counts and hematocrit may also reflect a decreased platelet function [ 36 ].The reason behind our findings are likely multifactorial. Consumption of platelet–fibrin clot formation probably early decreases platelet count, and this decrease is aggravated by dilution due to fluid resuscitation. Additional decreases in platelet count and function may be the result of consumptive depletion and exhaustion [ 8 ]. Platelet dysfunction could also be driven by endothelial injury [ 37 ] and structural changes following trauma, which could decrease their function [ 36 ]. Of note, we found that STBI with < 150 x 10 3 /µL platelets on ED arrival had a significant early drop in survival compared to non-thrombocytopenic patients. The definition of thrombocytopenia varies among studies, ranging from < 50 x 10 3 platelets/µL to < 150 x 10 3 platelets/µL [ 38 , 39 ], but a threshold of 100 x 10 3 platelets/µL seems to be the most frequently used definition of thrombocytopenia in trauma and this is also the target level referred to in the European trauma guidelines for patients with TBI [ 15 ] and Brain Trauma Foundation guidelines [ 12 ]. Despite of this, the quality of evidence that supports this hemostatic threshold in trauma is very low and was defined from small series of surgical patients, with isolated thrombocytopenia and not from severe trauma patients as well as they do not consider trauma-induced platelet dysfunction. Actually, It has been described that a platelet count < 175 x 10 3 platelets/µL is a significant predictor of PHI, while a lower count of < 100 x 10 3 platelets/µL is associated with a nine-fold adjusted risk of death in STBI [ 40 ]. Platelet-count declines more in patients with PHI [ 41 ], more severe injuries and older age [ 42 ], indicating that even a normal platelet count at admission might not be enough to rule out the risk of coagulopathy [ 43 ]. In our study, 88% of patients who died did it due to neurological causes (brain death or devastating brain injury). Still, as we did not assess subsequent cranial CT reports to demonstrate PHI, we cannot affirm if thrombocytopenia is a primary cause of mortality due to PHI or if it is secondary to other pathophysiological processes such as cerebral hemorrhage or raised intracranial pressure. Probably, most part of the mortality overserved is explained by the severity of the primary brain injury secondary exacerbated by a thrombocytopenia-induced PHI. So far, the role of platelets in trauma-induced coagulopathy remains unclear. Nevertheless, variations of platelet count within “normal ranges” reflect trauma severity, and several observational studies have confirmed that admission platelet count is a biomarker of trauma severity, associating with injury severity, shock intensity and with coagulopathy at admission [ 44 ]. Therefore, our findings regarding increased mortality associated with early thrombocytopenia are comparable with those of several previous studies [ 8 , 43 , 45 ], and suggest that low platelet count at ED arrival might perhaps exacerbate the primary and secondary brain injury through of PHI [ 46 ] but also that a low platelet count at ED arrival could be an indirect marker of a more severe brain injury and thereby, a higher mortality. In any case, what is clear is that patients with a very low platelet count are at higher risk of increased mortality, though the overall risk of death is also determined by other risk factors and coagulation disorders. In this respect, our study suggests that such thresholds may be insufficient after STBI associated with extracranial injury and exposes an additional argument to increase platelet transfusion threshold in order to prevent the initial hemorrhage to further expand and cause secondary injury. Whether platelet transfusion can reduce mortality induced by the thrombocytopenia after STBI is a question to be answered by appropriate future studies. Previous data have suggested that early platelet transfusion may have an independent role in survival after TBI [ 47 , 48 ] while small observational trials have suggested no efficacy of platelet transfusion after TBI despite documented thrombocytopenia or other platelet dysfunction [ 49 , 50 ]. Hence, it still remains uncertain whether early platelet transfusion would improve outcomes. Regarding fibrinogen levels, they raised in both groups at 24h after SICU admission, when non-survivors shown significant lower fibrinogen levels compared to survivors. This result may suggest an underlying hyperfibrinolysis mechanism in non-survivors, which has previously been associated with early mortality due to increased bleeding, while survivors would experience hypofibrinolysis or fibrinolysis shutdown, which modifies coagulopathy towards a less coagulopathic state [ 51 ]. Finally, an aggressive hemostatic resuscitation and pre-hospital fluid administration could worsen TBI-related coagulopathy by dilution, acidosis and hypothermia [ 43 ]. In our sample, there were no differences between survivors and non-survivors with respect to pre-hospital fluid replacement, time to hospital admission, hemodynamics, RBC transfusion or need of activation of MTP. Actually, STBI survivors had higher levels of hemoglobin within the first 24h after admission despite a higher rate of urgent surgery and neurosurgery, suggesting that an endogenous "early hypocoagulability state” would develop in some patients after STBI, since no differences in transfusion and pre-hospital fluids were observed, which would mainly affect the iatrogenic exogenous coagulopathy before and shortly after admission. The lower rates of urgent surgery and neurosurgery in the dead group may be explained by the presence of more serious injuries, with worse vital prognosis. In view of this, our result underline that age, GCS, and thrombocytopenia at ED arrival adversely affect polytrauma with STBI outcomes. In recent years, significant progress has been made in understanding STBI coagulopathy, but gaps remain as above discussed. Although we do not presently know whether the initial low platelet count is a causal factor of PHI or a coexisting marker of greater brain injury, our finding emphasizes the importance of identifying STBI patients with < 150 x 10 3 platelets/µL at ED arrival, since they are likely at a higher risk of death. For this reason, the platelet count at ED arrival should be assessed at admission in order to discriminate those patients which should be closely monitored because they can deteriorate in hours following trauma. In the future, prospective clinical trials should be designed as a priority to determine the beneficial effects of early treatment of thrombocytopenia. Limitations Our study has some limitations due to its retrospective design. First, we were unable to obtain more precise hemostatic lab data regarding platelet function, thromboelastography or clotting factor levels in order to better characterize the mechanisms underlying STBI-induced coagulopathy. However, these tests are labor intensive and require specialized equipment not available at all centers in the ED, which makes their application in the clinical setting difficult. Moreover, we did not have access to follow-up radiological data on intracranial hemorrhage progression. For this reason, we could not confirm a simple causal relationship between a low platelet count and PHI, which is also influenced by direct injury to blood vessels and inflammation caused by initial primary injury. Finally, we were unable to record differences in platelet transfusions between groups, although there is still a lack of clear evidence of mortality benefit of platelet transfusion in patients with TBI. Despite its limitations, we believe that clinically helpful and valid conclusions can be drawn from this research. Conclusions Older age, GCS score, and platelet count at ED arrival are independently associated with higher mortality in STBI patients with extracranial trauma. Thrombocytopenia < 150 × 10 3 platelets/µL at ED arrival is a simple prognostic tool to early predict survival or death between non-isolated STBI patients. Clinical trials are necessary to identify if interventions aiming to avoid early thrombocytopenia would improve outcomes in these patients. Declarations Author Contribution Patricia Piñeiro: conceptualization, investigation, methodology, project administration, resources, supervision, writing-review & editing. Alberto Calvo: conceptualization, resources, investigation, methodology, supervision, writing-original & draft. María Dolores PérezDíaz: investigation, methodology, resources. Silvia Ramos: conceptualization, investigation, methodology, resources. Sergio García-Ramos: conceptualization, investigation, methodology, resources. Mercedes Power: conceptualization, investigation, methodology, resources. Isabel Solchaga: conceptualization, investigation, methodology, resources. Cristina Rey: investigation, methodology, resources. Javier Hortal: investigation, methodology, visualization. Fernando Turégano: conceptualization, investigation, methodology, resources, supervision, writing-review & editing. Ignacio Garutti: conceptualization, investigation, methodology, project administration, formal analysis, resources, supervision, visualization, funding acquisition, writing-review & editing. Acknowledgement This article was funded by MSD & CO., INC, Kenilworth, NJ, USA. Data Availability All data generated or analyzed during this study are included in this published article. The database is available from the corresponding author . References Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines 2021;8:16. https://doi.org/10.3390/medicines8040016 . Maas AIR, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol 2008;7:728–41. https://doi.org/10.1016/S1474-4422(08)70164-9 . Harhangi BS, Kompanje EJO, Leebeek FWG, Maas AIR. Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 2008;150:165–75; discussion 175. https://doi.org/10.1007/s00701-007-1475-8 . Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008;65:748–54. https://doi.org/10.1097/TA.0b013e3181877a9c . Allard CB, Scarpelini S, Rhind SG, Baker AJ, Shek PN, Tien H, et al. Abnormal coagulation tests are associated with progression of traumatic intracranial hemorrhage. J Trauma 2009;67:959–67. https://doi.org/10.1097/TA.0b013e3181ad5d37 . van Gent JAN, van Essen TA, Bos MHA, Cannegieter SC, van Dijck JTJM, Peul WC. Coagulopathy after hemorrhagic traumatic brain injury, an observational study of the incidence and prognosis. Acta Neurochir (Wien) 2020;162:329–36. https://doi.org/10.1007/s00701-019-04111-z . Lustenberger T, Talving P, Kobayashi L, Inaba K, Lam L, Plurad D, et al. Time course of coagulopathy in isolated severe traumatic brain injury. Injury 2010;41:924–8. https://doi.org/10.1016/j.injury.2010.04.019 . Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, et al. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017;16:630–47. https://doi.org/10.1016/S1474-4422(17)30197-7 . Chang R, Fox EE, Greene TJ, Swartz MD, DeSantis SM, Stein DM, et al. Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS). Surgery 2018;163:819–26. https://doi.org/10.1016/j.surg.2017.10.050 . Watanabe T, Kawai Y, Iwamura A, Maegawa N, Fukushima H, Okuchi K. Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries. Neurol Med Chir (Tokyo) 2018;58:393–9. https://doi.org/10.2176/nmc.oa.2018-0116 . von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007;335:806–8. https://doi.org/10.1136/bmj.39335.541782.AD . Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017;80:6–15. https://doi.org/10.1227/NEU.0000000000001432 . Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1911–8. https://doi.org/10.1212/WNL.0b013e3181e242a8 . Harvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, et al. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth 2018;120:138–45. https://doi.org/10.1016/j.bja.2017.10.002 . Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019;23:98. https://doi.org/10.1186/s13054-019-2347-3 . Giner J, Mesa Galán L, Yus Teruel S, Guallar Espallargas MC, Pérez López C, Isla Guerrero A, et al. El traumatismo craneoencefálico severo en el nuevo milenio. Nueva población y nuevo manejo. Neurología 2022;37:383–9. https://doi.org/10.1016/j.nrl.2019.03.012 . Niemeyer M, Jochems D, Houwert RM, van Es MA, Leenen L, van Wessem K. Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients. Injury 2022;53:1443–8. https://doi.org/10.1016/j.injury.2022.01.009 . Patel HC, Bouamra O, Woodford M, Yates DW, Lecky FE. Clinical article: mortality associated with severe head injury in the elderly. Acta Neurochir (Wien) 2010;152:1353–7; discussion 1357. https://doi.org/10.1007/s00701-010-0666-x . Mosquera Betancourt G, Vega Basulto SD, Valdeblánquez Atencio J. Mortalidad por trauma craneoencefálico en el adulto mayor. Revista Archivo Médico de Camagüey 2009;13:0–0. Marshall LF, Maas AI, Marshall SB, Bricolo A, Fearnside M, Iannotti F, et al. A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury. J Neurosurg 1998;89:519–25. https://doi.org/10.3171/jns.1998.89.4.0519 . Moppett IK. Traumatic brain injury: assessment, resuscitation and early management. British Journal of Anaesthesia 2007;99:18–31. https://doi.org/10.1093/bja/aem128 . Reviejo K, Arcega I, Txoperena G, Azaldegui F, Alberdi F, Lara G. Análisis de factores pronósticos de la mortalidad en el traumatismo craneoencefálico grave. Proyecto Poliguitania. Med Intensiva 2002;26:241–7. Foreman BP, Caesar RR, Parks J, Madden C, Gentilello LM, Shafi S, et al. Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury. J Trauma 2007;62:946–50. https://doi.org/10.1097/01.ta.0000229796.14717.3a . Liu C, Xie J, Xiao X, Li T, Li H, Bai X, et al. Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma. International Journal of Medical Sciences 2021;18:1639. https://doi.org/10.7150/ijms.54913 . Tong W-S, Zheng P, Xu J-F, Guo Y-J, Zeng J-S, Yang W-J, et al. Early CT signs of progressive hemorrhagic injury following acute traumatic brain injury. Neuroradiology 2011;53:305–9. https://doi.org/10.1007/s00234-010-0659-8 . Maas AIR, Steyerberg EW, Butcher I, Dammers R, Lu J, Marmarou A, et al. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:303–14. https://doi.org/10.1089/neu.2006.0033 . Wardlaw JM, Easton VJ, Statham P. Which CT features help predict outcome after head injury? J Neurol Neurosurg Psychiatry 2002;72:188–92; discussion 151. https://doi.org/10.1136/jnnp.72.2.188 . Keimowitz RM, Annis BL. Disseminated intravascular coagulation associated with massive brain injury. J Neurosurg 1973;39:178–80. https://doi.org/10.3171/jns.1973.39.2.0178 . Fletcher-Sandersjöö A, Thelin EP, Maegele M, Svensson M, Bellander B-M. Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature. Neurocrit Care 2021;34:635–56. https://doi.org/10.1007/s12028-020-01037-8 . Liu J, Tian H-L. Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury. Chinese Journal of Traumatology 2016;19:172–5. https://doi.org/10.1016/j.cjtee.2016.01.011 . Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021;7:30. https://doi.org/10.1038/s41572-021-00264-3 . Tian H-L, Chen H, Wu B-S, Cao H-L, Xu T, Hu J, et al. D-dimer as a predictor of progressive hemorrhagic injury in patients with traumatic brain injury: analysis of 194 cases. Neurosurg Rev 2010;33:359–65; discussion 365–366. https://doi.org/10.1007/s10143-010-0251-z . Juratli TA, Zang B, Litz RJ, Sitoci K-H, Aschenbrenner U, Gottschlich B, et al. Early hemorrhagic progression of traumatic brain contusions: frequency, correlation with coagulation disorders, and patient outcome: a prospective study. J Neurotrauma 2014;31:1521–7. https://doi.org/10.1089/neu.2013.3241 . Carrick MM, Tyroch AH, Youens CA, Handley T. Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma 2005;58:725–9; discussion 729–730. https://doi.org/10.1097/01.ta.0000159249.68363.78 . Nekludov M, Bellander B-M, Blombäck M, Wallen HN. Platelet dysfunction in patients with severe traumatic brain injury. J Neurotrauma 2007;24:1699–706. https://doi.org/10.1089/neu.2007.0322 . Jacoby RC, Owings JT, Holmes J, Battistella FD, Gosselin RC, Paglieroni TG. Platelet Activation and Function after Trauma: The Journal of Trauma: Injury, Infection, and Critical Care 2001;51:639–47. https://doi.org/10.1097/00005373-200110000-00003 . Vulliamy P, Kornblith LZ, Kutcher ME, Cohen MJ, Brohi K, Neal MD. Alterations in platelet behavior after major trauma: adaptive or maladaptive? Platelets 2021;32:295–304. https://doi.org/10.1080/09537104.2020.1718633 . Yuan Q, Sun Y-R, Wu X, Yu J, Li Z-Q, Du Z-Y, et al. Coagulopathy in Traumatic Brain Injury and Its Correlation with Progressive Hemorrhagic Injury: A Systematic Review and Meta-Analysis. J Neurotrauma 2016;33:1279–91. https://doi.org/10.1089/neu.2015.4205 . Epstein DS, Mitra B, O’Reilly G, Rosenfeld JV, Cameron PA. Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: a systematic review and meta-analysis. Injury 2014;45:819–24. https://doi.org/10.1016/j.injury.2014.01.011 . Schnüriger B, Inaba K, Abdelsayed GA, Lustenberger T, Eberle BM, Barmparas G, et al. The impact of platelets on the progression of traumatic intracranial hemorrhage. J Trauma 2010;68:881–5. https://doi.org/10.1097/TA.0b013e3181d3cc58 . Engström M, Romner B, Schalén W, Reinstrup P. Thrombocytopenia predicts progressive hemorrhage after head trauma. J Neurotrauma 2005;22:291–6. https://doi.org/10.1089/neu.2005.22.291 . Nakae R, Yokobori S, Takayama Y, Kuwamoto K, Naoe Y, Yokota H. Age-related differences in fibrinolytic parameters in patients with acute traumatic brain injury. Surg Neurol Int 2017;8:214. https://doi.org/10.4103/sni.sni_56_17 . Lillemäe K, Luostarinen T, Reinikainen M, Bendel S, Laitio R, Hoppu S, et al. Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 2022;164:2731–40. https://doi.org/10.1007/s00701-022-05277-9 . Brown LM, Call MS, Margaret Knudson M, Cohen MJ, Trauma Outcomes Group, Holcomb JB, et al. A normal platelet count may not be enough: the impact of admission platelet count on mortality and transfusion in severely injured trauma patients. J Trauma 2011;71:S337-342. https://doi.org/10.1097/TA.0b013e318227f67c . Böhm JK, Güting H, Thorn S, Schäfer N, Rambach V, Schöchl H, et al. Global Characterisation of Coagulopathy in Isolated Traumatic Brain Injury (iTBI): A CENTER-TBI Analysis. Neurocrit Care 2021;35:184–96. https://doi.org/10.1007/s12028-020-01151-7 . Hamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, et al. Impact of platelet transfusion on outcomes in trauma patients. Critical Care 2022;26:49. https://doi.org/10.1186/s13054-022-03928-y . Stansbury LG, Dutton RP, Stein DM, Bochicchio GV, Scalea TM, Hess JR. Controversy in trauma resuscitation: do ratios of plasma to red blood cells matter? Transfus Med Rev 2009;23:255–65. https://doi.org/10.1016/j.tmrv.2009.06.002 . Cardenas JC, Zhang X, Fox EE, Cotton BA, Hess JR, Schreiber MA, et al. Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial. Blood Adv 2018;2:1696–704. https://doi.org/10.1182/bloodadvances.2018017699 . Kutcher ME, Redick BJ, McCreery RC, Crane IM, Greenberg MD, Cachola LM, et al. Characterization of platelet dysfunction after trauma. J Trauma Acute Care Surg 2012;73:13–9. https://doi.org/10.1097/TA.0b013e318256deab . Alvikas J, Zenati M, Campwala I, Jansen JO, Hassoune A, Phelos H, et al. Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study. J Trauma Acute Care Surg 2022;92:167–76. https://doi.org/10.1097/TA.0000000000003427 . Meizoso JP, Moore HB, Moore EE, Gilna GP, Ghasabyan A, Chandler J, et al. Traumatic brain injury provokes low fibrinolytic activity in severely injured patients. J Trauma Acute Care Surg 2022;93:8–12. https://doi.org/10.1097/TA.0000000000003559 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4697908","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":333206492,"identity":"74e40942-9f50-4409-a4c5-83999923f4a6","order_by":0,"name":"Patricia Piñeiro","email":"","orcid":"","institution":"Hospital General Universitario Gregorio Marañón","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"Piñeiro","suffix":""},{"id":333206493,"identity":"ed3d0725-efee-43cf-965c-4106ac5943c9","order_by":1,"name":"Alberto 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18:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4697908/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4697908/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62189385,"identity":"9dca2eff-35c1-4b18-b394-4ea06b325748","added_by":"auto","created_at":"2024-08-10 12:21:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":124599,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of patients included in the study.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4697908/v1/b7699a502d2cc774646dd95d.jpeg"},{"id":62189386,"identity":"d9c748ec-11a9-4640-8a5d-17f1165f818a","added_by":"auto","created_at":"2024-08-10 12:21:36","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130901,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier survival curve for patients with a platelet count of \u0026gt; or \u0026lt; 150,000/\u003c/strong\u003eμ\u003cstrong\u003eL. \u003c/strong\u003eKaplan-Meier survival curves are displayed to discriminate patients arriving at emergency department with \u0026gt; 150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/μL (green) and \u0026lt; 150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/μL (blue). The matched groups were compared using the log-rank test. Patients admitted with \u0026lt; 150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/μL had significantly higher and earlier mortality than those admitted with \u0026gt; 150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/μL (p\u0026lt;0.001).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4697908/v1/2a607a1afaa15727807b345b.jpeg"},{"id":66241532,"identity":"b1a6a217-91ec-42ba-b80b-a7b847694c93","added_by":"auto","created_at":"2024-10-09 06:47:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1038258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4697908/v1/68c73358-3793-41a8-b2a7-616b008064e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early thrombocytopenia at hospital admission predicts mortality in patients with non-isolated severe traumatic brain injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSevere traumatic brain injury (STBI) is one of the main causes of death and disability throughout the world, yet associated neurological morbidity and mortality have not decreased significantly during the last 30 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrognosis of patients with STBI is still uncertain, and multiple studies try to identify predictors of outcome in these patients. Patients with STBI often have intracranial bleeding which can be accompanied by secondary injury. This secondary injury may consist of brain swelling and progression of hemorrhagic injury (PHI) which, ultimately, could form a risk of herniation and death [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition, STBI patients who suffer a traumatic intracranial hemorrhage remained at risk for developing a coagulopathy after trauma. After STBI, hemostasis is often derailed, leading to a hypocoagulopathic and\u0026mdash;less often\u0026mdash;a hypercoagulopathic state [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] depending on injury pattern, presence of hypoperfusion, endothelial damage, hemostatic treatment, individual responses, genetic predisposition, and comorbidities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The presence of coagulopathy is a well-recognized predictor of poor outcomes in patients with STBI, being associated with increased rates of disability and mortality due to the increased risk of PHI and brain edema progression [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoagulopathy is usually defined as low platelet count or elevated international normalized ratio (INR), prothrombin time (PT) or activated partial thromboplastin time (APTT) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the incidence and the degree to which a specific coagulopathy of STBI contributes to the overall burden of TBI mortality remains unclear, although platelet count and dysfunction and coagulopathy appear to be relevant factors in isolated STBI [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, STBI patients with associated extracranial trauma are difficult to diagnose and manage, and may associate more hypotension and coagulopathy resulting from extracranial injuries, which further darkens the prognosis compared to isolated STBI [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. On this basis, there is a lack of insight into STBI-associated coagulopathy that clearly contrasts with their potential clinical consequences.\u003c/p\u003e \u003cp\u003eTherefore, we aimed to study the influence of hemostatic abnormalities evaluated at the emergency department (ED) and hemostasis during the first 48 hours after STBI to further determine whether dead non-isolated STBI patients show a different hemostatic admission profile compared to non-isolated STBI survivors. Secondly, we also investigate whether other epidemiological and clinical characteristics were associated with increased risk of mortality in these patients. In that case, STBI patients with associated extracranial trauma patients should be better characterized, and we could potentially implement earlier strategies to improve clinical outcomes.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eWe performed an observational descriptive retrospective study in a Level II equivalent trauma center (Gregorio Mara\u0026ntilde;\u0026oacute;n Universitary General Hospital) between 2015\u0026ndash;2021 years. This study follows [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The study was approved by the research ethical committee of our institution (Drug Research Ethics committee of Gregorio Mara\u0026ntilde;\u0026oacute;n Universitary General Hospital). All research was performed in accordance the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for retrospective cohort studies and with the Declaration of Helsinki. Due to its retrospective nature, informed consent was waived by our research ethical committee regulations.\u003c/p\u003e \u003cp\u003ePatients were recruited from our local trauma registry. Inclusion criteria were patients with non-isolated severe TBI [defined as Injury Severity Score (ISS)\u0026thinsp;\u0026ge;\u0026thinsp;16 with an \u003cem\u003eAbbreviated Injury Scale\u003c/em\u003e \u003cb\u003e(\u003c/b\u003eAIS) head and neck\u0026thinsp;\u0026ge;\u0026thinsp;3 and Glasgow Coma Scale (GCS)\u0026thinsp;\u0026le;\u0026thinsp;8], \u0026ge; 18 years old, admitted within 6 hours of injury to our center. We excluded patients who were taking antiplatelet and or anticoagulant medication, pregnant women, as well as those with liver disease, chronic kidney disease on hemodialysis, chronic alcoholic or previous hemostatic disease as well as patients with diffuse axonal injury due its due to their possible role on hemostatic and neurological disturbances.\u003c/p\u003e \u003cp\u003eDuring the study period a total of 151 STBI patients were admitted to our center. After excluding 17 patients, 134 patients composed the study group. Patients included were further analyzed in two subgroups: survivors (83) and dead (51) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eAll patients were initially admitted to the ED for the initial assistance. Afterwards, they were transferred to the radiology or operating room depending on their clinical stability. On admission, all patients were clinically evaluated by a neurosurgeon and underwent a head computed tomography (CT) scan, except when extracranial surgery was necessary for immediate damage control, when the head computed tomography scan was performed at the end of surgery. All evaluations of CT scans were extracted from the original report by the radiologist. Acute brain injuries assessed by CT imaging included the following: epidural hematoma (EDH), subdural hematoma (SDH), subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH) and skull fracture. Volumes of EDH, SDH, and parenchymal/hemorrhagic contusions were measured. In addition, status of the ambient cisterns and the presence of midline shift were assessed. The indication for neurosurgery was established by the neurosurgery staff in accordance with the recommendations established by the international guidelines for the surgical management of TBI [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In general, the surgical criteria were based on the level of consciousness, neurological focality, hematoma volume and/or thickness, presence of signs of cisternal compression, deviation of the midline\u0026thinsp;\u0026gt;\u0026thinsp;5 mm or maintained (\u0026gt;\u0026thinsp;1 hour) refractory intracranial pressure (\u0026gt;\u0026thinsp;25 mmHg). After radiological study and/or surgery patients were admitted to the surgical intensive care unit (SICU). The cause of death was obtained from the death report of the chart. Brain death was defined as irreversible cessation of vital activity of the whole brain (including the brainstem), verified by well-defined neurological clinical protocols and specialized tests (radiographic test and/or electroencephalogram) following international guidelines [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, devastating brain injury was defined as any neurological condition assessed at the time of hospital admission, which represented an immediate threat to life or incompatible with good functional recovery, and where early limitation or withdrawal of therapy was considered [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifferent epidemiological and clinical data were compared between groups: age, sex, time to hospital admission, cause of accident, pre-hospital fluid replacement, hemodynamics (heart rate and arterial blood pressure), neurologic parameters [GCS at admission, Glasgow Outcome Score (GOS) at discharge], trauma severity (ISS, AIS, AIS head and neck), length of stay in SICU, red blood cells (RBC) transfusions, need of massive transfusion protocol (MTP), need of urgent surgery and neurosurgery, and associated extracranial injury. MTP was activated when Assessment of Blood Consumption (ABC) score was \u0026ge;\u0026thinsp;2.\u003c/p\u003e \u003cp\u003eLaboratory blood tests were collected by arterial samples at different standardized times as part of our routine patient care: arrival to ED, admission to SICU, 24h after SICU admission, 48h after SICU admission. Blood samples were taken to determine INR, PT and APTT, as well as values for fibrinogen, hemoglobin, and platelets, on arrival to the emergency department, admission to the SICU, and at 24 hours and 48 hours after admission to the SICU. Thrombocytopenia was defined as a platelet count less than 150 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L based on most extended threshold in the literature [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eAll data generated or analyzed during this study are included in this published article. The database is available from the corresponding author.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using the IBM SPSS software package (IL, USA, version 21.0). Categorical data are expressed as percentages. Quantitative data are shown as mean (standard deviation) for normally distributed data, while non-normally distributed data are expressed as median (interquartile range). We made a univariate analysis with mortality during hospital stay. Medians for numerical variables were compared between groups for continuous data using the Mann-Whitney test, and χ\u003csup\u003e2\u003c/sup\u003e test or Fisher\u0026rsquo;s exact test (when appropriate) to compare categorical variables. We then performed a logistic regression analysis for mortality including variables which had a p value less than 0.1 in univariate analysis. Finally, for survival analysis according to platelet count\u0026thinsp;\u0026lt;\u0026thinsp;or \u0026gt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L, the Kaplan-Meier method was used and the curves were compared using the Log-Rank test. Statistical significance was set at 0.05 p-value.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the observation period (2015\u0026ndash;2021), a total of 151 non-isolated STBI patients were admitted to our center. 134 patients composed the study group. Out of these 134 patients, 83 (62%) survived and 51 (38%) died. Regarding those who deceased, 45 (88%) died from neurological causes (brain death or devastating brain injury) and only 6 patients died from non-neurological causes such us hemorrhagic shock or limitation of therapy. 50% of patients died within 48 hours of admission to hospital.\u003c/p\u003e \u003cp\u003eDemographic and clinical characteristics of these STBI are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients who died were significantly older, male sex and experienced less motorcycle collisions (15.6% vs 24.1%, p\u0026thinsp;=\u0026thinsp;0.011). They also significantly shown higher ISS (41 vs 34, p\u0026thinsp;=\u0026thinsp;0.003) and AIS head and neck (5 vs 4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) while GCS (5 vs 4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), GOS (1 vs 3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), need of urgent surgery (35% vs 70%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and length of stay in SICU (2 vs 17, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were lower comparing to STBI survivors. No statistical differences between both groups were observed regarding to time to reach hospital, pre-hospital fluid replacement, other mechanisms of accidents, hemodynamics (systolic arterial pressure, heart rate), AIS overall, massive transfusion protocol activation and RBC transfusions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEpidemiological and clinical characteristics of non-isolated severe traumatic brain injury patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvivors (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDead (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (29.75\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (29\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (36\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (64.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (63.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (64.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime taken to reach hospital (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (41\u0026ndash;61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (43\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (40\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanism of trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Car, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Motorcycle, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (20.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Knocked down, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (32.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (30.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Fall, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (37.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-hospital fluid replacement (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e600 (300\u0026ndash;1200)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e650 (300\u0026ndash;1275)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e600 (200\u0026ndash;1100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic arterial pressure (mm Hg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (90\u0026ndash;140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119 (90\u0026ndash;136)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120 (81\u0026ndash;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate (bpm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (79.75\u0026ndash;120.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (82\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (79\u0026ndash;124)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlasgow score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5 (3\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (4\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS, head and neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS, overall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (8\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (5\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (29\u0026ndash;43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (27\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (34\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay in SICU (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3\u0026ndash;25.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (8\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRed blood cell units, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0\u0026ndash;6.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMTP, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for urgent surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed of urgent neurosurgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (26.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCategorical data are shown in sample size (n) and percentages. Quantitative data are shown as median (percentile 25-percentile 75) as no normally distributed. Abbreviations: n, number; IQR, interquartile range; min, minutes; mL, milliliters; bpm, beats per minute; AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; MTP, massive transfusion protocol; GOS: Glasgow Outcome Score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the radiological findings of the initial CT scan performed on admission (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), we observed that in the dead group, most patients sustained traumatic SAH (58.8%), and SDH (56.9%), followed by cerebral contusion (27.5%) and IPH (23.5%), while in the survivors\u0026rsquo; group, most patients experienced traumatic SAH (56%), followed by SDH (41.7%) and cerebral contusion (35.7%). Skull fractures were also common in both groups (54.9% vs 40.5%). However, significant differences were only found between the both groups in terms of IPH (23.5% vs 2.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), cerebral contusion (23.5% vs 35.7%, p\u0026thinsp;=\u0026thinsp;0.03) and radiological signs of brain herniation (23.5% vs 7.1, p\u0026thinsp;=\u0026thinsp;0.007). No statistical differences were observed regarding the need for urgent neurosurgery between both groups (23.5% vs 28.9%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeuroradiological findings in admission CT.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvivors (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003cp\u003en, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDead (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003cp\u003en, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (58.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (56.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.771\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral contusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (27.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrainstem hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrain swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (13.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrain herniation sings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkull fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (40.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCategorical data are shown in sample size and percentages. Abbreviations: n, number; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage; EDH, epidural hemorrhage; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn our sample, the most frequent associated extracranial injuries in both groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) were those affecting the thorax (66.42%) and skeleton (65.67%), followed in order of frequency by the spinal column (47.01%), abdomen (34.33%), pelvis (31.34%), face (30.60%), retroperitoneal space (29.73%) and liver (28.21%). Extracranial injuries were equally distributed between STBI patients who survived and STBI patients who died, except for cervical spinal cord (50.6% vs 41.2%), thorax (72.2% vs 56.8%) and liver (20.5% vs 9.8%) injuries, where more common in patients who survived. However, no statistical differences with respect to extracranial injuries were observed between survivors and non-survivors.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociated extracranial injury of non-isolated severe traumatic brain injury patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvivors\u003c/p\u003e \u003cp\u003en, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDead\u003c/p\u003e \u003cp\u003en, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (30.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63 (47.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (50.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMediastinum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (6.72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (66.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (72.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (34.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (36.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (31.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (31.34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (30.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkeleton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88 (65.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (66.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (64.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (28.21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (20.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpleen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (13.24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive hemoperitoneum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiaphragm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (15.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetroperitoneal hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (29.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.723\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCategorical data are shown in sample size and percentages. Abbreviations: n, number.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn order to study the laboratory abnormalities in hemostasis after STBI we analyze differences between survivors and dead in regard to clotting values and platelet count during the first 48 hours (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Within first 24 hours, INR and APTT deteriorated gradually in both groups while PT increased in patients who survived and remained stable in those who died. After 48 hours, INR, APTT and PT return to normal values. We only found significant differences regarding clotting parameters between survivors and dead STBI patients at SICU admission time, when dead patients showed prolonged INR, APTT and PT times comparing to survivors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, fibrinogen levels increased exponentially at 24 hours after SICU admission in both groups, at which point there were significant differences between survivors and dead (517 vs 424, p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory results for clotting parameters, hemoglobin and platelet count since admission to 48 hours in the SICU.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eEmergency Department arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eSICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e24 hours at SICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e48 hours at SICU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eINR \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvivors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.07 (1.00-1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.11 (1.02\u0026ndash;1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.16 (1.06\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.10 (1.02\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.18 (1.01\u0026ndash;1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.19 (1.08\u0026ndash;1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.19 (1.08\u0026ndash;1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.11 (1.04\u0026ndash;1.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAPTT\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvivors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.8 (26.5\u0026ndash;34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.5 (26.2\u0026ndash;32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.1 (27.4\u0026ndash;31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29.0 (27.3\u0026ndash;31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.9 (25.8\u0026ndash;45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.0 (26.4\u0026ndash;43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.7 (26.3\u0026ndash;33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29.7 (26.6\u0026ndash;33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePT\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvived\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.8 (11.8\u0026ndash;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.2 (12.1\u0026ndash;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.9 (12.6\u0026ndash;15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.2 (12.0\u0026ndash;14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDied\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1 (12.0\u0026ndash;17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3 (12.9\u0026ndash;18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.2 (12.8\u0026ndash;17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.2 (12.3\u0026ndash;16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFib\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvivors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.8 (11.8\u0026ndash;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.2 (12.1\u0026ndash;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.9 (12.6\u0026ndash;15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.2 (12.0\u0026ndash;14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1 (12.0\u0026ndash;17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3 (12.9\u0026ndash;18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.2 (12.8\u0026ndash;17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.2 (12.3\u0026ndash;16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHb\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvivors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.4 (10.5\u0026ndash;13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.8 (10.4\u0026ndash;13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.2 (9.2\u0026ndash;11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.1 (8.2\u0026ndash;10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5 (7.8\u0026ndash;13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.1 (8.6\u0026ndash;12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.8 (8.7\u0026ndash;11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.5 (8.4\u0026ndash;10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePC\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(x 10\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurvivors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200 (159\u0026ndash;238)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e192 (134\u0026ndash;235)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e143 (108\u0026ndash;176)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e124 (100\u0026ndash;164)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149 (114\u0026ndash;184)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e130 (98\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e107 (81\u0026ndash;129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e92 (70\u0026ndash;130)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eQuantitative data are shown as median (percentile 25-percentile 75) as no normally distributed. Abbreviations: IQR, interquartile range; pl, platelets; INR, International Normalized Ratio; APTT, activated partial prothrombin time; Fib, fibrinogen; PT, prothrombin time; Hb, hemoglobin; PC, platelet count; SICU, surgical intensive care unit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn addition, Platelet count also decreased progressively after STBI in both groups, highlighting a marked initial lower platelet count recorded in patients who eventually died. Interestingly, we found that while platelet levels remained stable among patients who survived and only began to fall after 24 hours, in patients who died, platelet levels decreased since ED arrival. In fact, platelet count was significantly lower in dead STBI patients when compared to survivors at all measured times (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hemoglobin levels decreased clearly in both groups, with statistically significant lower values in dead STBI patients at ED arrival (p\u0026thinsp;=\u0026thinsp;0.01) and SICU admission (p\u0026thinsp;=\u0026thinsp;0.001). Furthermore, when we performed the Kaplan Meier survival curve (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) for admitted patients with a platelet count less than 150 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L we observed that ED admitted patients with \u0026lt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L had a significant early drop in survival compared to those admitted with \u0026gt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L to the ED (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), although both curves stabilized during the first few days after STBI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFinally, the logistic regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) revealed that age, GCS and platelet count were at ED arrival were independently associated with an increase in mortality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical results of the logistic regression analysis for mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlasgow coma scale score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.797\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet count on ED admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConstant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAbbreviations: B, estimated parameter; S.E, standard error; df, degrees of freedom; sig., signification; Exp(B), B exponential.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study investigating a sample of STBI patients with associated extracranial trauma during 7 years showed the predictive value of blood routine tests at admission and clinical characteristics for mortality outcomes, highlighting the usefulness of early assessment of platelet count and function and the need to develop treatment strategies for coagulation abnormalities in non-isolated STBI patients.\u003c/p\u003e \u003cp\u003eIn terms of clinical characteristics, STBI mortality is highly influenced by epidemiological and clinical characteristics [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our cohort, patients who died were older and mostly male sex. Remarkably, the logistic regression model pointed out to age as an independent predictor of STBI-mortality, in accordance with the literature [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This higher risk of mortality in older STBI patients might be explained due to their poor cardiovascular reserve in response to the stress generated by trauma, attenuation of cerebral autoregulation mechanisms, less tolerance to cerebral ischemia, comorbidities or greater postoperative complications in case of urgent surgery [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Likewise, males usually show higher mortality rates among the series [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] because the number of males included in TBI studies is higher than female due to their increased probability of injury (motor vehicle collisions, sports and suicides) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our study also revealed a lower incidence of death in motorcycle collisions, owing to the additional protection of wearing helmet [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAssessment of overall injury severity is considered of fundamental importance in the clinical outcome of patients who suffer STBI with extracranial trauma. In our sample, non-survivor STBI showed a higher ISS and head and neck AIS scores, lower GCS and GOS, as compared to survivors. These findings are consistent with previous studies which correlate higher AIS and ISS as well as lower GCS with worse neurological prognosis (GOS score) ant STBI mortality [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We did not confirm the ability of all these scores to predict the prognosis of STBI patients in a logistic regression model. In contrast, our study confirmed that only age and admission GCS score can be used as independent predictors of mortality in STBI patients with extracranial trauma, as previous evidence has correlated it [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to clinical features, cranial CT scans play an important role in the diagnosis and prognosis of STBI. The most common CT findings in both groups were traumatic SAH (58.8%) and SDH (56.9%) followed by cerebral contusion (27.5%). Notably, non-survivors had more IPH, swelling and radiological signs of brain herniation comparing to survivors, in which cerebral contusion was more frequent. For this reason, due to the similar proportion of surgically treatable lesions in both groups, as well as the presence of a higher number of initial poor prognosis lesions that discourage surgical treatment in the dead group, no differences were found in the number of urgent neurosurgeries between groups. In this regard, previous studies have demonstrated that some initial CT findings such as signs of brain shift and intraparenchymal hemorrhage are more likely to have PHI [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], coagulopathy and mortality [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients who sustained a traumatic intracranial hemorrhage and/or increased ICP at admission CT scan remain at risk for developing a coagulopathy until 72 h after trauma, showing worse clinical outcomes than patients who do not develop a coagulopathy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Coagulation disorders in TBI are complex and are characterized by consumption of clotting factors and platelets, platelet dysfunction, and hyperfibrinolysis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Although coagulation abnormalities have been studied previously in the isolated TBI population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] this is one of the few reports showing the occurrence of a coagulopathy in STBI patients who present traumatic intracranial hemorrhage with associated extracranial injuries.\u003c/p\u003e \u003cp\u003eDiagnostic criteria for coagulopathy are inconsistent in the literature, but it may be recognized by conventional lab tests [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our study, we observed that clotting parameters, platelets, and hemoglobin deteriorated gradually from admission until 48 hours, with significant differences between groups depending on the measured time. We only found statistical differences between survivors and dead regarding PT, INR and APTT at admission to the SICU. This abnormalities between ED arrival and SICU admission might be explained because lab test at SICU admission are usually done some hours after the injury and ED arrival, reflecting that hemostatic function changes over time as compensatory mechanisms are engaged and inflammation progresses [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Different previous studies have shown inconsistent results regarding conventional clotting test. The incidence of an elevated PT, INR or APTT in TBI varies widely, from 1\u0026ndash;31% [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], mostly affected by testing time and injury severity. In a recent systematic review, Fletcher-Sandersj\u0026ouml;\u0026ouml; [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] found that most of studies noted that TBI was followed by a decrease in markers of coagulation cascade function. Furthermore, not all patients with abnormalities in laboratory coagulation tests are bleeding [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In fact, Juratli and coworkers [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] found no significant difference in relation to an elongated INR or APTT and PHI. Thus, PT, INR or APTT have not been proved to be a risk factor or an exclusive indicator of PHI [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found that the platelets count at ED admission was the only significant blood parameter in multivariate logistic regression model, apart from age and GCS score. In our study, platelet levels significantly decreased in both groups after STBI, highlighting a lower platelet count since arrival to ED in patients who eventually died. This decrease in platelet count appeared to be independent of other hemostatic disorders (liver insufficiency, alcohol consumption, etc.) and antithrombic therapy. Our results are consistent with Carrick\u0026rsquo;s report [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], who found that patients with moderate and STBI are at risk of developing progressive thrombocytopenia after admission. Besides platelet count, platelet dysfunction has been shown to be present after TBI, contributing also to hemorrhagic complications [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. We were not able to measure platelet function, but it is assumed that decreased platelet counts and hematocrit may also reflect a decreased platelet function [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].The reason behind our findings are likely multifactorial. Consumption of platelet\u0026ndash;fibrin clot formation probably early decreases platelet count, and this decrease is aggravated by dilution due to fluid resuscitation. Additional decreases in platelet count and function may be the result of consumptive depletion and exhaustion [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Platelet dysfunction could also be driven by endothelial injury [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and structural changes following trauma, which could decrease their function [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf note, we found that STBI with \u0026lt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e /\u0026micro;L platelets on ED arrival had a significant early drop in survival compared to non-thrombocytopenic patients. The definition of thrombocytopenia varies among studies, ranging from \u0026lt;\u0026thinsp;50 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L to \u0026lt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], but a threshold of 100 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L seems to be the most frequently used definition of thrombocytopenia in trauma and this is also the target level referred to in the European trauma guidelines for patients with TBI [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Brain Trauma Foundation guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite of this, the quality of evidence that supports this hemostatic threshold in trauma is very low and was defined from small series of surgical patients, with isolated thrombocytopenia and not from severe trauma patients as well as they do not consider trauma-induced platelet dysfunction. Actually, It has been described that a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;175 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L is a significant predictor of PHI, while a lower count of \u0026lt;\u0026thinsp;100 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L is associated with a nine-fold adjusted risk of death in STBI [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Platelet-count declines more in patients with PHI [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], more severe injuries and older age [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], indicating that even a normal platelet count at admission might not be enough to rule out the risk of coagulopathy [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In our study, 88% of patients who died did it due to neurological causes (brain death or devastating brain injury). Still, as we did not assess subsequent cranial CT reports to demonstrate PHI, we cannot affirm if thrombocytopenia is a primary cause of mortality due to PHI or if it is secondary to other pathophysiological processes such as cerebral hemorrhage or raised intracranial pressure. Probably, most part of the mortality overserved is explained by the severity of the primary brain injury secondary exacerbated by a thrombocytopenia-induced PHI.\u003c/p\u003e \u003cp\u003eSo far, the role of platelets in trauma-induced coagulopathy remains unclear. Nevertheless, variations of platelet count within \u0026ldquo;normal ranges\u0026rdquo; reflect trauma severity, and several observational studies have confirmed that admission platelet count is a biomarker of trauma severity, associating with injury severity, shock intensity and with coagulopathy at admission [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Therefore, our findings regarding increased mortality associated with early thrombocytopenia are comparable with those of several previous studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and suggest that low platelet count at ED arrival might perhaps exacerbate the primary and secondary brain injury through of PHI [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] but also that a low platelet count at ED arrival could be an indirect marker of a more severe brain injury and thereby, a higher mortality. In any case, what is clear is that patients with a very low platelet count are at higher risk of increased mortality, though the overall risk of death is also determined by other risk factors and coagulation disorders.\u003c/p\u003e \u003cp\u003eIn this respect, our study suggests that such thresholds may be insufficient after STBI associated with extracranial injury and exposes an additional argument to increase platelet transfusion threshold in order to prevent the initial hemorrhage to further expand and cause secondary injury. Whether platelet transfusion can reduce mortality induced by the thrombocytopenia after STBI is a question to be answered by appropriate future studies. Previous data have suggested that early platelet transfusion may have an independent role in survival after TBI [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] while small observational trials have suggested no efficacy of platelet transfusion after TBI despite documented thrombocytopenia or other platelet dysfunction [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Hence, it still remains uncertain whether early platelet transfusion would improve outcomes.\u003c/p\u003e \u003cp\u003eRegarding fibrinogen levels, they raised in both groups at 24h after SICU admission, when non-survivors shown significant lower fibrinogen levels compared to survivors. This result may suggest an underlying hyperfibrinolysis mechanism in non-survivors, which has previously been associated with early mortality due to increased bleeding, while survivors would experience hypofibrinolysis or fibrinolysis shutdown, which modifies coagulopathy towards a less coagulopathic state [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, an aggressive hemostatic resuscitation and pre-hospital fluid administration could worsen TBI-related coagulopathy by dilution, acidosis and hypothermia [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In our sample, there were no differences between survivors and non-survivors with respect to pre-hospital fluid replacement, time to hospital admission, hemodynamics, RBC transfusion or need of activation of MTP. Actually, STBI survivors had higher levels of hemoglobin within the first 24h after admission despite a higher rate of urgent surgery and neurosurgery, suggesting that an endogenous \"early hypocoagulability state\u0026rdquo; would develop in some patients after STBI, since no differences in transfusion and pre-hospital fluids were observed, which would mainly affect the iatrogenic exogenous coagulopathy before and shortly after admission. The lower rates of urgent surgery and neurosurgery in the dead group may be explained by the presence of more serious injuries, with worse vital prognosis.\u003c/p\u003e \u003cp\u003eIn view of this, our result underline that age, GCS, and thrombocytopenia at ED arrival adversely affect polytrauma with STBI outcomes. In recent years, significant progress has been made in understanding STBI coagulopathy, but gaps remain as above discussed. Although we do not presently know whether the initial low platelet count is a causal factor of PHI or a coexisting marker of greater brain injury, our finding emphasizes the importance of identifying STBI patients with \u0026lt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L at ED arrival, since they are likely at a higher risk of death. For this reason, the platelet count at ED arrival should be assessed at admission in order to discriminate those patients which should be closely monitored because they can deteriorate in hours following trauma. In the future, prospective clinical trials should be designed as a priority to determine the beneficial effects of early treatment of thrombocytopenia.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur study has some limitations due to its retrospective design. First, we were unable to obtain more precise hemostatic lab data regarding platelet function, thromboelastography or clotting factor levels in order to better characterize the mechanisms underlying STBI-induced coagulopathy. However, these tests are labor intensive and require specialized equipment not available at all centers in the ED, which makes their application in the clinical setting difficult. Moreover, we did not have access to follow-up radiological data on intracranial hemorrhage progression. For this reason, we could not confirm a simple causal relationship between a low platelet count and PHI, which is also influenced by direct injury to blood vessels and inflammation caused by initial primary injury. Finally, we were unable to record differences in platelet transfusions between groups, although there is still a lack of clear evidence of mortality benefit of platelet transfusion in patients with TBI. Despite its limitations, we believe that clinically helpful and valid conclusions can be drawn from this research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOlder age, GCS score, and platelet count at ED arrival are independently associated with higher mortality in STBI patients with extracranial trauma. Thrombocytopenia\u0026thinsp;\u0026lt;\u0026thinsp;150 \u0026times; 10\u003csup\u003e3\u003c/sup\u003e platelets/\u0026micro;L at ED arrival is a simple prognostic tool to early predict survival or death between non-isolated STBI patients. Clinical trials are necessary to identify if interventions aiming to avoid early thrombocytopenia would improve outcomes in these patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePatricia Pi\u0026ntilde;eiro: conceptualization, investigation, methodology, project administration, resources, supervision, writing-review \u0026amp; editing. Alberto Calvo: conceptualization, resources, investigation, methodology, supervision, writing-original \u0026amp; draft. Mar\u0026iacute;a Dolores P\u0026eacute;rezD\u0026iacute;az: investigation, methodology, resources. Silvia Ramos: conceptualization, investigation, methodology, resources. Sergio Garc\u0026iacute;a-Ramos: conceptualization, investigation, methodology, resources. Mercedes Power: conceptualization, investigation, methodology, resources. Isabel Solchaga: conceptualization, investigation, methodology, resources. Cristina Rey: investigation, methodology, resources. Javier Hortal: investigation, methodology, visualization. Fernando Tur\u0026eacute;gano: conceptualization, investigation, methodology, resources, supervision, writing-review \u0026amp; editing. Ignacio Garutti: conceptualization, investigation, methodology, project administration, formal analysis, resources, supervision, visualization, funding acquisition, writing-review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis article was funded by MSD \u0026amp; CO., INC, Kenilworth, NJ, USA.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this published article. The database is available from the corresponding author .\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSavioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines 2021;8:16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/medicines8040016\u003c/span\u003e\u003cspan address=\"10.3390/medicines8040016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaas AIR, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol 2008;7:728\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(08)70164-9\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(08)70164-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarhangi BS, Kompanje EJO, Leebeek FWG, Maas AIR. Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 2008;150:165\u0026ndash;75; discussion 175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00701-007-1475-8\u003c/span\u003e\u003cspan address=\"10.1007/s00701-007-1475-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008;65:748\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e3181877a9c\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e3181877a9c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllard CB, Scarpelini S, Rhind SG, Baker AJ, Shek PN, Tien H, et al. Abnormal coagulation tests are associated with progression of traumatic intracranial hemorrhage. J Trauma 2009;67:959\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e3181ad5d37\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e3181ad5d37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Gent JAN, van Essen TA, Bos MHA, Cannegieter SC, van Dijck JTJM, Peul WC. Coagulopathy after hemorrhagic traumatic brain injury, an observational study of the incidence and prognosis. Acta Neurochir (Wien) 2020;162:329\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00701-019-04111-z\u003c/span\u003e\u003cspan address=\"10.1007/s00701-019-04111-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLustenberger T, Talving P, Kobayashi L, Inaba K, Lam L, Plurad D, et al. Time course of coagulopathy in isolated severe traumatic brain injury. Injury 2010;41:924\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2010.04.019\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2010.04.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaegele M, Sch\u0026ouml;chl H, Menovsky T, Mar\u0026eacute;chal H, Marklund N, Buki A, et al. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017;16:630\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(17)30197-7\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(17)30197-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang R, Fox EE, Greene TJ, Swartz MD, DeSantis SM, Stein DM, et al. Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS). Surgery 2018;163:819\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.surg.2017.10.050\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2017.10.050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe T, Kawai Y, Iwamura A, Maegawa N, Fukushima H, Okuchi K. Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries. Neurol Med Chir (Tokyo) 2018;58:393\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2176/nmc.oa.2018-0116\u003c/span\u003e\u003cspan address=\"10.2176/nmc.oa.2018-0116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007;335:806\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.39335.541782.AD\u003c/span\u003e\u003cspan address=\"10.1136/bmj.39335.541782.AD\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarney N, Totten AM, O\u0026rsquo;Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017;80:6\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1227/NEU.0000000000001432\u003c/span\u003e\u003cspan address=\"10.1227/NEU.0000000000001432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1911\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1212/WNL.0b013e3181e242a8\u003c/span\u003e\u003cspan address=\"10.1212/WNL.0b013e3181e242a8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, et al. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth 2018;120:138\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bja.2017.10.002\u003c/span\u003e\u003cspan address=\"10.1016/j.bja.2017.10.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019;23:98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13054-019-2347-3\u003c/span\u003e\u003cspan address=\"10.1186/s13054-019-2347-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiner J, Mesa Gal\u0026aacute;n L, Yus Teruel S, Guallar Espallargas MC, P\u0026eacute;rez L\u0026oacute;pez C, Isla Guerrero A, et al. El traumatismo craneoencef\u0026aacute;lico severo en el nuevo milenio. Nueva poblaci\u0026oacute;n y nuevo manejo. Neurolog\u0026iacute;a 2022;37:383\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nrl.2019.03.012\u003c/span\u003e\u003cspan address=\"10.1016/j.nrl.2019.03.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiemeyer M, Jochems D, Houwert RM, van Es MA, Leenen L, van Wessem K. Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients. Injury 2022;53:1443\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2022.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2022.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel HC, Bouamra O, Woodford M, Yates DW, Lecky FE. Clinical article: mortality associated with severe head injury in the elderly. Acta Neurochir (Wien) 2010;152:1353\u0026ndash;7; discussion 1357. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00701-010-0666-x\u003c/span\u003e\u003cspan address=\"10.1007/s00701-010-0666-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosquera Betancourt G, Vega Basulto SD, Valdebl\u0026aacute;nquez Atencio J. Mortalidad por trauma craneoencef\u0026aacute;lico en el adulto mayor. Revista Archivo M\u0026eacute;dico de Camag\u0026uuml;ey 2009;13:0\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarshall LF, Maas AI, Marshall SB, Bricolo A, Fearnside M, Iannotti F, et al. A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury. J Neurosurg 1998;89:519\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/jns.1998.89.4.0519\u003c/span\u003e\u003cspan address=\"10.3171/jns.1998.89.4.0519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoppett IK. Traumatic brain injury: assessment, resuscitation and early management. British Journal of Anaesthesia 2007;99:18\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bja/aem128\u003c/span\u003e\u003cspan address=\"10.1093/bja/aem128\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReviejo K, Arcega I, Txoperena G, Azaldegui F, Alberdi F, Lara G. An\u0026aacute;lisis de factores pron\u0026oacute;sticos de la mortalidad en el traumatismo craneoencef\u0026aacute;lico grave. Proyecto Poliguitania. Med Intensiva 2002;26:241\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForeman BP, Caesar RR, Parks J, Madden C, Gentilello LM, Shafi S, et al. Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury. J Trauma 2007;62:946\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.ta.0000229796.14717.3a\u003c/span\u003e\u003cspan address=\"10.1097/01.ta.0000229796.14717.3a\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Xie J, Xiao X, Li T, Li H, Bai X, et al. Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma. International Journal of Medical Sciences 2021;18:1639. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7150/ijms.54913\u003c/span\u003e\u003cspan address=\"10.7150/ijms.54913\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong W-S, Zheng P, Xu J-F, Guo Y-J, Zeng J-S, Yang W-J, et al. Early CT signs of progressive hemorrhagic injury following acute traumatic brain injury. Neuroradiology 2011;53:305\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00234-010-0659-8\u003c/span\u003e\u003cspan address=\"10.1007/s00234-010-0659-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaas AIR, Steyerberg EW, Butcher I, Dammers R, Lu J, Marmarou A, et al. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:303\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2006.0033\u003c/span\u003e\u003cspan address=\"10.1089/neu.2006.0033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWardlaw JM, Easton VJ, Statham P. Which CT features help predict outcome after head injury? J Neurol Neurosurg Psychiatry 2002;72:188\u0026ndash;92; discussion 151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/jnnp.72.2.188\u003c/span\u003e\u003cspan address=\"10.1136/jnnp.72.2.188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeimowitz RM, Annis BL. Disseminated intravascular coagulation associated with massive brain injury. J Neurosurg 1973;39:178\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/jns.1973.39.2.0178\u003c/span\u003e\u003cspan address=\"10.3171/jns.1973.39.2.0178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher-Sandersj\u0026ouml;\u0026ouml; A, Thelin EP, Maegele M, Svensson M, Bellander B-M. Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature. Neurocrit Care 2021;34:635\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12028-020-01037-8\u003c/span\u003e\u003cspan address=\"10.1007/s12028-020-01037-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Tian H-L. Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury. Chinese Journal of Traumatology 2016;19:172\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cjtee.2016.01.011\u003c/span\u003e\u003cspan address=\"10.1016/j.cjtee.2016.01.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021;7:30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41572-021-00264-3\u003c/span\u003e\u003cspan address=\"10.1038/s41572-021-00264-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian H-L, Chen H, Wu B-S, Cao H-L, Xu T, Hu J, et al. D-dimer as a predictor of progressive hemorrhagic injury in patients with traumatic brain injury: analysis of 194 cases. Neurosurg Rev 2010;33:359\u0026ndash;65; discussion 365\u0026ndash;366. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10143-010-0251-z\u003c/span\u003e\u003cspan address=\"10.1007/s10143-010-0251-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJuratli TA, Zang B, Litz RJ, Sitoci K-H, Aschenbrenner U, Gottschlich B, et al. Early hemorrhagic progression of traumatic brain contusions: frequency, correlation with coagulation disorders, and patient outcome: a prospective study. J Neurotrauma 2014;31:1521\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2013.3241\u003c/span\u003e\u003cspan address=\"10.1089/neu.2013.3241\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrick MM, Tyroch AH, Youens CA, Handley T. Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma 2005;58:725\u0026ndash;9; discussion 729\u0026ndash;730. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.ta.0000159249.68363.78\u003c/span\u003e\u003cspan address=\"10.1097/01.ta.0000159249.68363.78\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNekludov M, Bellander B-M, Blomb\u0026auml;ck M, Wallen HN. Platelet dysfunction in patients with severe traumatic brain injury. J Neurotrauma 2007;24:1699\u0026ndash;706. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2007.0322\u003c/span\u003e\u003cspan address=\"10.1089/neu.2007.0322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacoby RC, Owings JT, Holmes J, Battistella FD, Gosselin RC, Paglieroni TG. Platelet Activation and Function after Trauma: The Journal of Trauma: Injury, Infection, and Critical Care 2001;51:639\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00005373-200110000-00003\u003c/span\u003e\u003cspan address=\"10.1097/00005373-200110000-00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVulliamy P, Kornblith LZ, Kutcher ME, Cohen MJ, Brohi K, Neal MD. Alterations in platelet behavior after major trauma: adaptive or maladaptive? Platelets 2021;32:295\u0026ndash;304. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09537104.2020.1718633\u003c/span\u003e\u003cspan address=\"10.1080/09537104.2020.1718633\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan Q, Sun Y-R, Wu X, Yu J, Li Z-Q, Du Z-Y, et al. Coagulopathy in Traumatic Brain Injury and Its Correlation with Progressive Hemorrhagic Injury: A Systematic Review and Meta-Analysis. J Neurotrauma 2016;33:1279\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2015.4205\u003c/span\u003e\u003cspan address=\"10.1089/neu.2015.4205\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein DS, Mitra B, O\u0026rsquo;Reilly G, Rosenfeld JV, Cameron PA. Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: a systematic review and meta-analysis. Injury 2014;45:819\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2014.01.011\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2014.01.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchn\u0026uuml;riger B, Inaba K, Abdelsayed GA, Lustenberger T, Eberle BM, Barmparas G, et al. The impact of platelets on the progression of traumatic intracranial hemorrhage. J Trauma 2010;68:881\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e3181d3cc58\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e3181d3cc58\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngstr\u0026ouml;m M, Romner B, Schal\u0026eacute;n W, Reinstrup P. Thrombocytopenia predicts progressive hemorrhage after head trauma. J Neurotrauma 2005;22:291\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2005.22.291\u003c/span\u003e\u003cspan address=\"10.1089/neu.2005.22.291\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakae R, Yokobori S, Takayama Y, Kuwamoto K, Naoe Y, Yokota H. Age-related differences in fibrinolytic parameters in patients with acute traumatic brain injury. Surg Neurol Int 2017;8:214. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/sni.sni_56_17\u003c/span\u003e\u003cspan address=\"10.4103/sni.sni_56_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLillem\u0026auml;e K, Luostarinen T, Reinikainen M, Bendel S, Laitio R, Hoppu S, et al. Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 2022;164:2731\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00701-022-05277-9\u003c/span\u003e\u003cspan address=\"10.1007/s00701-022-05277-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown LM, Call MS, Margaret Knudson M, Cohen MJ, Trauma Outcomes Group, Holcomb JB, et al. A normal platelet count may not be enough: the impact of admission platelet count on mortality and transfusion in severely injured trauma patients. J Trauma 2011;71:S337-342. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e318227f67c\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e318227f67c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eB\u0026ouml;hm JK, G\u0026uuml;ting H, Thorn S, Sch\u0026auml;fer N, Rambach V, Sch\u0026ouml;chl H, et al. Global Characterisation of Coagulopathy in Isolated Traumatic Brain Injury (iTBI): A CENTER-TBI Analysis. Neurocrit Care 2021;35:184\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12028-020-01151-7\u003c/span\u003e\u003cspan address=\"10.1007/s12028-020-01151-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, et al. Impact of platelet transfusion on outcomes in trauma patients. Critical Care 2022;26:49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13054-022-03928-y\u003c/span\u003e\u003cspan address=\"10.1186/s13054-022-03928-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStansbury LG, Dutton RP, Stein DM, Bochicchio GV, Scalea TM, Hess JR. Controversy in trauma resuscitation: do ratios of plasma to red blood cells matter? Transfus Med Rev 2009;23:255\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.tmrv.2009.06.002\u003c/span\u003e\u003cspan address=\"10.1016/j.tmrv.2009.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardenas JC, Zhang X, Fox EE, Cotton BA, Hess JR, Schreiber MA, et al. Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial. Blood Adv 2018;2:1696\u0026ndash;704. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1182/bloodadvances.2018017699\u003c/span\u003e\u003cspan address=\"10.1182/bloodadvances.2018017699\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKutcher ME, Redick BJ, McCreery RC, Crane IM, Greenberg MD, Cachola LM, et al. Characterization of platelet dysfunction after trauma. J Trauma Acute Care Surg 2012;73:13\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e318256deab\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e318256deab\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvikas J, Zenati M, Campwala I, Jansen JO, Hassoune A, Phelos H, et al. Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study. J Trauma Acute Care Surg 2022;92:167\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0000000000003427\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000003427\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeizoso JP, Moore HB, Moore EE, Gilna GP, Ghasabyan A, Chandler J, et al. Traumatic brain injury provokes low fibrinolytic activity in severely injured patients. J Trauma Acute Care Surg 2022;93:8\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0000000000003559\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000003559\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Traumatic brain injury, intracranial hemorrhage, coagulopathy, thrombocytopenia, mortality, emergency department.","lastPublishedDoi":"10.21203/rs.3.rs-4697908/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4697908/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatients with severe traumatic brain injury (STBI) often experience an abnormal hemostasis that contributes to mortality and unfavorable neurological outcomes. We aimed to analyze epidemiologic, clinical and laboratory factors associated with mortality in patients with severe traumatic brain injury during the first 48 hours after in-hospital admission.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed an observational retrospective study of STBI patients with associated extracranial trauma [defined as Injury Severity Score (ISS)\u0026thinsp;\u0026ge;\u0026thinsp;16 with an \u003cem\u003eAbbreviated Injury Scale\u003c/em\u003e \u003cb\u003e(\u003c/b\u003eAIS) head and neck\u0026thinsp;\u0026ge;\u0026thinsp;3 and Glasgow Coma Scale (GCS)\u0026thinsp;\u0026le;\u0026thinsp;8], admitted to a Level II trauma center over 7 years (2015\u0026ndash;2021). Patients were divided in 2 groups: survivors and dead. We assessed differences regarding demographics, trauma severity, hemodynamics, disability, need of surgery, length of stay, transfusions, need of massive transfusion protocol and hemostatic laboratory parameters at different time points.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e134 STBI patients were included. Patients who died were older, mostly men and showed higher trauma severity and disability. Hemoglobin, platelets and clotting parameters deteriorated after admission to the emergency department (ED) with significant differences between groups within the first 24h after admission. Platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150 \u0026times; 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L at ED arrival, Glasgow coma scale and age were independent risk factors for mortality.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOlder age, Glasgow coma scale and platelet count at ED arrival were independent risk factors for mortality in STBI patients with associated extracranial trauma. Early thrombocytopenia\u0026thinsp;\u0026lt;\u0026thinsp;150 \u0026times; 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L at ED arrival may be used as a simple prognostic tool to early predict mortality between non-isolated STBI.\u003c/p\u003e","manuscriptTitle":"Early thrombocytopenia at hospital admission predicts mortality in patients with non-isolated severe traumatic brain injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-10 12:21:31","doi":"10.21203/rs.3.rs-4697908/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0cbb34b-9578-4232-b884-a90934f7f27e","owner":[],"postedDate":"August 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":35280194,"name":"Health sciences/Neurology"},{"id":35280195,"name":"Health sciences/Diseases/Trauma"}],"tags":[],"updatedAt":"2024-10-09T06:39:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-10 12:21:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4697908","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4697908","identity":"rs-4697908","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}