Early bilateral pulmonary embolism in a polytrauma patient: About a case report

Introduction

and importance: Venous thromboembolism (VTE) is a well-known complication in polytrauma patients, associated with a high rate of mortality and morbidity. Generally pulmonary embolism (PE) is most common between the fifth and seventh days following a significant trauma, and it is uncommon before the fourth day. Their management remains a challenge to physicians given the nature and risk of blood loss from the accompanying injuries must be considered while using anticoagulant therapy.

Case presentation

Here we present a case of acute pulmonary embolism in a previously healthy young woman that developed two days after a traumatic brain injury (TBI) and varying degrees of additional blunt thoracic trauma. An angio CT scan was used to make the diagnosis, and the patient was given anticoagulant medication with close monitoring and satisfactory outcomes.

Conclusion

Evidence suggests that early after trauma, a considerable number of trauma patients are hypercoagulable. In patients with unexplained dyspnea/hypoxia, clinicians should maintain a high index of suspicion and explore PE early after injury. In the case of traumatic brain injury patients with cerebral contusions, intraparenchymal haemorrhages, or subdural/extradural haemorrhages, the existence of post-traumatic PE adds to the problems.

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Our aim was to investigate the (PE) in polytrauma patients: incidence, risk factors of early occurrence, management and outcomes.

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Decision to anti-coagulate post traumatic PE is controversial, especially in polytrauma patients.

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Anticoagulation decision is guided by interval repeat CT scan and clinical picture.

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The presence of post traumatic PE poses further challenges in the management of traumatic brain injury patients with cerebral contusions, intraparenchymal haemorrhages or subdural/extradural haemorrhages.

Decoding health status transitions of over 200 000 patients with traumatic brain injury from preceding injury to the injury event

For centuries, the study of traumatic brain injury (TBI) has been centred on historical observation and analyses of personal, social, and environmental processes, which have been examined separately. Today, computation implementation and vast patient data repositories can enable a concurrent analysis of personal, social, and environmental processes, providing insight into changes in health status transitions over time. We applied computational and data visualization techniques to categorize decade-long health records of 235,003 patients with TBI in Canada, from preceding injury to the injury event itself. Our results highlighted that health status transition patterns in TBI emerged along with the projection of comorbidity where many disorders, social and environmental adversities preceding injury are reflected in external causes of injury and injury severity. The strongest associations between health status preceding TBI and health status at the injury event were between multiple body system pathology and advanced age-related brain pathology networks. The interwoven aspects of health status on a time continuum can influence post-injury trajectories and should be considered in TBI risk analysis to improve prevention, diagnosis, and care.

Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences

Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.

The Formation of Microthrombi in Parenchymal Microvessels after Traumatic Brain Injury Is Independent of Coagulation Factor XI

Microthrombus formation and bleeding worsen the outcome after traumatic brain injury (TBI). The aim of the current study was to characterize these processes in the brain parenchyma after experimental TBI and to determine the involvement of coagulation factor XI (FXI). C57BL/6 mice (n = 101) and FXI-deficient mice (n = 15) were subjected to controlled cortical impact (CCI). Wild-type mice received an inhibitory antibody against FXI (14E11) or control immunoglobulin G 24 h before or 30 or 120 min after CCI. Cerebral microcirculation was visualized in vivo by 2-photon microscopy 2-3 h post-trauma and histopathological outcome was assessed after 24 h. TBI induced hemorrhage and microthrombus formation in the brain parenchyma (p < 0.001). Inhibition of FXI activation or FXI deficiency did not reduce cerebral thrombogenesis, lesion volume, or hemispheric swelling. However, it also did not increase intracranial hemorrhage. Formation of microthrombosis in the brain parenchyma after TBI is independent of the intrinsic coagulation cascade since it was not reduced by inhibition of FXI. However, since targeting FXI has well-established antithrombotic effects in humans and experimental animals, inhibition of FXI could represent a reasonable strategy for the prevention of deep venous thrombosis in immobilized patients with TBI.

Anticoagulation Therapy in Traumatic Brain Injury

BACKGROUND

Optimal anticoagulation therapy (AT) in patients with traumatic brain injury (TBI) is a challenging task and proper management is strongly correlated with clinical outcomes. Only limited data are available on AT after TBI and practical decision making is based on the opinion of experts. This review sought to critically assess different therapeutic options using AT and antiplatelet agents in the perioperative period after TBI.

METHODS

A comprehensive review of the literature was performed to summarize relevant data on AT in patients with TBI.

RESULTS

Patients with preinjury AT with TBI require emergent neurosurgical treatment and they are also at high risk of developing thromboembolic complications or hematoma expansion. New oral anticoagulants offer a lower incidence of intracranial hemorrhage compared with warfarin. The rate of intracranial hemorrhage during new oral anticoagulants or heparin therapy is significantly lower than that with vitamin K antagonists.