Evaluation of Antitrombin-III in multiple traumatic patients with trauma scores in the Emergency Department

It was reported that, the risk of thrombo-emboli increases with the age and the severity of the trauma for the patients with multiple trauma [7,8,10]. It was shown by a study of Nast-Kolp et al. in Germany [11] that there is a relationship between the severity of the trauma and the AT-III level. It was shown by a study of Risberg et al. [16] on 20 patients with multiple trauma that the levels of AT-III and alpha-plasmine inhibitors decrease. In another study carried out by Erichsen et al. [17], this was also proved on 19 patients.

Also in our study, there was a strong negative linear correlation between the injury day AT-III level and the ISS score (r=-0.49, p=0.005, Beta=-0.78, 95% CI=-0.94;-0.29) . The injury day AT-III levels (39.7±8.9 mg/dl) of the patients with severe multiple trauma whose ISS scores were higher than 25 were lower than that of the patients with mild multiple trauma (39.7±8.9 mg/dl); but both of the levels were in the normal ranges (p=0.006, 95% CI=17.3;-3.2). For the same group, the fibrinogen level was found to be high on the injury day (p=0.02). There was no statistical difference between the other values. When all the groups are of our concern, there was no significant difference in the AT-III, aPTT, fibrinogen and thrombocyte levels between the 0th day and the 3rd day (p>0.05) while PT level decreased on the 3rd day (p=0.0006).

In a study carried out in Denmark by Sorensen et al. [20] , it was shown that isolated head trauma and multiple trauma might cause an  increase the levels of Prothrombin fragment 1 & 2 (F 1+2) and thrombin /AT-III complex (TAT) which reflect the haemostatic activation. This study shows us that AT-III is used in complex forms for the patients with multiple trauma. Decreasing the AT-III level in our study is also due to the same reason. Furthermore, in Sorensen et al. [20], a better haemostatic response trend was achieved for the patients with multiple trauma compared to the patients with isolated head trauma. 

This indicates that, a good haemostatic response causes the AT-III level to decrease, which also conforms to the results of our study. In the study of Sorensen et al. [20], F1+2 and TAT levels decrease day by day after the trauma. This means that AT-III should have been used less during the following days after the trauma and this shows us that AT-III levels would increase. A difference in the AT-III level had also been observed between day 0 and the 3rd day in our study. These results are also compatible with the study of Bick [2] and other studies by Sorensen et al. [19,21,22].

Sorensen and friends observed that, the TAT level was higher for patients with multiple trauma compared to the patients with head trauma [20]. This means that AT-III was used more for the patients with multiple trauma. The levels of AT-III was found to be low for Group II which comprises of patients with severe multiple trauma also in our study (Table 7). The F1+2 and TAT levels are also strongly related to the ISS scores for the first three days in the same study [20]. Also in our study, the AT-III levels decreased for the patients with high ISS scores.

Low AT-III, fibrinogen, high fibrinogen destruction products level and thrombocytopenia together with agency dysfunctions are generally considered as the diagnostic criteria for the disseminate intravascular coagulation (DIC) [2]. The monocytes and the injury macrophages system are activated during the first 24 - 72 hours after the injury [3,12]. The cytokines and the continuous coagulation activity by the procoagulan activity may also take part. It was reported that, the infusion of tumor necrotizing factor (TNF) causes the F1+2 levels to increase in the humans [1]. It was also reported that, DIC is a general complication of severe head trauma and multiple trauma [2,6,14,15,23]. This makes us think that, for these patients the coagulation system works harder which causes AT-III level to decrease. 

As a result; it is concluded that, the risk of thrombo-emboli increases for the patients who attempts to the Emergency Service with multiple trauma, so their treatment should be planned accordingly.