BACKGROUND/OBJECTIVE Multivariable prognostic scores play an important role for clinical decision-making, information giving to patients/relatives, benchmarking and guiding clinical trial design. Coagulopathy has been implicated on trauma and critical care outcomes, but few studies have evaluated its role on traumatic brain injury (TBI) outcomes. Our objective was to verify the incremental prognostic value of routine coagulopathy parameters in addition to the CRASH-CT score to predict 14-day mortality in TBI patients. METHODS This is a prospective cohort of consecutive TBI patients admitted to a tertiary university hospital Trauma intensive care unit (ICU) from March/2012 to January/2015. The prognostic performance of the coagulation parameters platelet count, prothrombin time (international normalized ratio, INR) and activated partial thromboplastin time (aPTT) ratio was assessed through logistic regression adjusted for the original CRASH-CT score. A new model, CRASH-CT-Coag, was created and its calibration (Brier scores and Hosmer-Lemeshow (H-L) test), discrimination [area under the receiver operating characteristic curve (AUC-ROC) and the integrated discrimination improvement (IDI)] and clinical utility (net reclassification index) were compared to the original CRASH-CT score. RESULTS A total 517 patients were included (median age 39 years, 85.1% male, median admission glasgow coma scale 8, neurosurgery on 44.9%). The 14-day mortality observed and predicted by the original CRASH-CT was 22.8% and 26.2%, respectively. Platelet count < 100,000/mm3, INR > 1.2 and aPTT ratio > 1.2 were present on 11.3%, 65.0% and 27.2%, respectively, (at least one of these was altered on 70.6%). All three variables maintained statistical significance after adjustment for the CRASH-CT score. The CRASH-CT-Coag score outperformed the original score on calibration (brier scores 0.122 ± 0.216 vs 0.132 ± 0.202, mean difference 0.010, 95% CI 0.005-0.019, p = 0.036, respectively) and discrimination (AUC-ROC 0.854 ± 0.020 vs 0.813 ± 0.024, p = 0.014; IDI 5.0%, 95% CI 1.3-11.0%). Both scores showed the satisfactory H-L test results. The net reclassification index favored the new model. Considering the strata of low (< 10%), moderate (10-30%) and high (> 30%) risk of death, the CRASH-CT-Coag model yielded a global net correct reclassification of 22.9% (95% CI 3.8-43.4%). CONCLUSIONS The addition of early markers of coagulopathy-platelet count, INR and aPTT ratio-to the CRASH-CT score increased its accuracy. Additional studies are required to externally validate this finding and further investigate the coagulopathy role on TBI outcomes.

中文翻译：

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除了创伤性脑损伤患者的碰撞评分外，凝血病的增量预后价值。

背景/目标 多变量预后评分在临床决策、向患者/亲属提供信息、基准测试和指导临床试验设计方面发挥着重要作用。凝血病与创伤和重症监护结果有关，但很少有研究评估其对创伤性脑损伤 (TBI) 结果的作用。我们的目标是验证常规凝血障碍参数以及 CRASH-CT 评分对预测 TBI 患者 14 天死亡率的增量预后价值。方法 这是 2012 年 3 月至 2015 年 1 月期间在三级大学医院创伤重症监护室 (ICU) 连续收治的 TBI 患者的前瞻性队列。凝血参数血小板计数、凝血酶原时间（国际标准化比值、INR) 和活化部分凝血活酶时间 (aPTT) 比率通过调整原始 CRASH-CT 评分的逻辑回归进行评估。创建了一个新模型 CRASH-CT-Coag，并对其校准（Brier 评分和 Hosmer-Lemeshow (HL) 测试）、辨别力 [接受者操作特征曲线下面积 (AUC-ROC) 和综合辨别力改进 (IDI) ] 和临床效用（净重分类指数）与原始 CRASH-CT 评分进行了比较。结果 共纳入 517 名患者（中位年龄 39 岁，85.1% 男性，入院中位格拉斯哥昏迷评分 8，神经外科 44.9%）。原始 CRASH-CT 观察和预测的 14 天死亡率分别为 22.8% 和 26.2%。血小板计数 < 100,000/mm3，INR > 1.2 和 aPTT 比率 > 1.2 分别为 11.3%、65.0% 和 27.2%，（其中至少一项在 70.6% 上发生了改变）。在调整 CRASH-CT 评分后，所有三个变量均保持统计学显着性。CRASH-CT-Coag 得分优于校准的原始得分（brier 得分 0.122 ± 0.216 vs 0.132 ± 0.202，平均差 0.010，95% CI 0.005-0.019，p = 0.036，分别）和歧视（AUC-ROC 0.854 ± 0.020与 0.813 ± 0.024，p = 0.014；IDI 5.0%，95% CI 1.3-11.0%）。两个分数都显示出令人满意的 HL 测试结果。净重分类指数有利于新模型。考虑到低 (< 10%)、中 (10-30%) 和高 (> 30%) 死亡风险的层次，CRASH-CT-Coag 模型产生了 22.9% 的全球净正确重新分类 (95% CI 3.8 -43.4%）。结论 凝血病血小板计数早期标志物的添加，INR 和 aPTT 与 CRASH-CT 评分的比率提高了其准确性。需要额外的研究来外部验证这一发现并进一步研究凝血障碍对 TBI 结果的作用。