Multiple Organ Dysfunction in Patients With Brain Injury

Figure 60.1 Algorithm for the diagnosis of left ventricular dysfunction in severe neurological patients. Modified from [Mayer, 1995].

* Q waves, ST elevation or other changes diagnostic of acute ischemia.

60.4 Coagulopathy

It is known that coagulopathy is associated with severe TBI, particularly penetrating injuries. It is also believed that the presence of coagulopathy worsens the prognosis of these patients, being an unfavourable outcome. However, the features, the pathophysiology, and the real incidence of coagulopathy associated with severe TBI are not fully understood. Some studies showed an initial state of hypercoagulability, followed by a state of increased fibrinolysis or disseminated intravascular coagulation. This last possibility could predispose or aggravate a multiple organ failure.

A recent study evaluating 436 patients with severe TBI noted coagulopathy associated in 36% of cases, being more frequent in the more severe cases and penetrating injuries. This study also showed that this combination significantly increases mortality. What complicates the analysis of studies on coagulopathy associated with severe TBI is the lack of consistency in diagnostic criteria for coagulopathy, whether they are clinical, laboratory, or temporal. Besides, it is unclear whether correction of coagulation abnormalities improves the outcome of these patients.

60.5 Key Concepts

Non-neurological organ dysfunction is common in patients with severe TBI and is independently associated with worse functional outcome and higher mortality. Pulmonary dysfunctions are more common in TBI patients, occurring in 25-50% of patients. The etiology of these changes is multifactorial, which complicates specific preventive strategies.

The impact of PEEP on ICP is not linear and is unpredictable. Generally, PEEP up to 15 cmH₂O does not cause significant changes in ICP. However, ICP monitoring is recommended in all cases of severe TBI in which PEEP >8-10 cmH₂O may be necessary.

Cardiovascular disorders are also frequent and, especially when triggered states of low cardiac output have a significant impact on morbidity and mortality.

Although the pathophysiology of coagulation disorders associated with TBI is not fully understood, it is well recognized that these changes are indicators of an unfavourable outcome.

General References

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