BACKGROUND

Traumatic brain injury (TBI) and hemorrhagic shock (HS) can be associated with coagulopathy and inflammation, but the mechanisms are poorly understood. We hypothesized that a combination of TBI and HS would disturb coagulation, damage the endothelium, and activate inflammatory and complement systems.

METHODS

A total of 33 swine were allocated to either TBI+ HS (n= 27, TBI and volume-controlled 40% blood loss) or controls (n= 6, anesthesia and instrumentation). TBI+ HS animals were left hypotensive (mean arterial pressure, 30–35 mm Hg) for 2 hours. Blood samples were drawn at baseline, 3 minutes and 15 minutes after injury, as well as following 2 hours of hypotension. Markers of coagulation, anticoagulation, endothelial activation/glycocalyx shedding, inflammation, complement, and sympathoadrenal function were measured.

RESULTS

The TBI+ HS group demonstrated an immediate (3 minutes after injury) activation of coagulation (prothrombin fragment 1+ 2, 289 ng/mL vs. 232 ng/mL, p= 0.03) and complement (C5a, 2.83 ng/mL vs. 2.05 ng/mL, p= 0.05). Shedding of the endothelial glycocalyx (syndecan 1) was evident 15 minutes after injury (851.0 ng/ml vs. 715.5 ng/ml, p= 0.03) while inflammation (tumor necrosis factor α [TNF-α], 81.1 pg/mL vs. 50.8 pg/mL, p= 0.03) and activation of the protein C system (activated protein C, 56.7 ng/mL vs. 26.1 ng/mL, p= 0.01) were evident following the 2-hour hypotension phase.

CONCLUSION

The combination of TBI and shock results in an immediate activation of coagulation and complement systems with subsequent endothelial shedding, protein C activation, and inflammation.