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Erschienen in: Notfall +  Rettungsmedizin 7/2014

01.11.2014 | Leitthema

Blutungen und Gerinnungsstörungen beim Polytrauma

Aktueller Stand der Diagnostik und des Managements bei traumaassoziierten Koagulopathien

verfasst von: PD Dr. S. Wutzler, M. Maegele, T. Lustenberger, F. Hildebrand, R. Lefering, M. Frink, I. Marzi, Die Sektion Trauma der DIVI

Erschienen in: Notfall + Rettungsmedizin | Ausgabe 7/2014

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Zusammenfassung

Hintergrund

Unkontrollierbare Blutungen sind eine der führenden Todesursachen beim Traumapatienten.

Fragestellung

Die Entwicklungen und Empfehlungen der Akuttherapie traumatischer Blutungen sollen dargestellt werden.

Material und Methode

Übersichtsarbeit unter Berücksichtigung aktueller Studien und den 2013 überarbeiteten „European Guidelines“.

Ergebnisse

Klare Empfehlungen hinsichtlich Basis- und erweiterter Diagnostik, externer Maßnahmen und Substitution von Gerinnungs- und Blutprodukten können gegeben werden.

Schlussfolgerung

Kliniken der Traumaversorgung sollten einen individuellen, an die lokalen Gegebenheiten und internationalen Empfehlungen angelehnten Algorithmus zur Therapie der traumaassoziierten Koagulopathie vorhalten.
Literatur
1.
Zurück zum Zitat Baraniuk S, Tilley BC, Del Junco DJ et al (2014) Pragmatic randomized optimal platelet and plasma ratios (PROPPR) trial: design, rationale and implementation. Injury 45:1287–1295PubMedCrossRef Baraniuk S, Tilley BC, Del Junco DJ et al (2014) Pragmatic randomized optimal platelet and plasma ratios (PROPPR) trial: design, rationale and implementation. Injury 45:1287–1295PubMedCrossRef
2.
Zurück zum Zitat Bellamy RF (1984) The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 149:55–62PubMed Bellamy RF (1984) The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 149:55–62PubMed
3.
Zurück zum Zitat Borgman MA, Spinella PC, Holcomb JB et al (2011) The effect of FFP: RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang 101:44–54PubMedCentralPubMedCrossRef Borgman MA, Spinella PC, Holcomb JB et al (2011) The effect of FFP: RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang 101:44–54PubMedCentralPubMedCrossRef
4.
Zurück zum Zitat Borgman MA, Spinella PC, Perkins JG et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63:805–813PubMedCrossRef Borgman MA, Spinella PC, Perkins JG et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63:805–813PubMedCrossRef
5.
Zurück zum Zitat Brohi K, Cohen MJ, Davenport RA (2007) Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 13:680–685PubMedCrossRef Brohi K, Cohen MJ, Davenport RA (2007) Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 13:680–685PubMedCrossRef
6.
Zurück zum Zitat Brohi K, Cohen MJ, Ganter MT et al (2007) Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 245:812–818PubMedCentralPubMedCrossRef Brohi K, Cohen MJ, Ganter MT et al (2007) Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 245:812–818PubMedCentralPubMedCrossRef
7.
8.
Zurück zum Zitat Engstrom M, Schott U, Romner B et al (2006) Acidosis impairs the coagulation: a thromboelastographic study. J Trauma 61:624–628PubMedCrossRef Engstrom M, Schott U, Romner B et al (2006) Acidosis impairs the coagulation: a thromboelastographic study. J Trauma 61:624–628PubMedCrossRef
9.
Zurück zum Zitat Esposito TJ, Sanddal ND, Hansen JD et al (1995) Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma 39:955–962PubMedCrossRef Esposito TJ, Sanddal ND, Hansen JD et al (1995) Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma 39:955–962PubMedCrossRef
10.
Zurück zum Zitat Gonzalez EA, Moore FA, Holcomb JB et al (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 62:112–119PubMedCrossRef Gonzalez EA, Moore FA, Holcomb JB et al (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 62:112–119PubMedCrossRef
11.
Zurück zum Zitat Guyatt G, Gutterman D, Baumann MH et al (2006) Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. Chest 129:174–181PubMedCrossRef Guyatt G, Gutterman D, Baumann MH et al (2006) Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. Chest 129:174–181PubMedCrossRef
12.
Zurück zum Zitat Hauser CJ, Boffard K, Dutton R et al (2010) Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma 69:489–500PubMedCrossRef Hauser CJ, Boffard K, Dutton R et al (2010) Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma 69:489–500PubMedCrossRef
13.
Zurück zum Zitat Hess JR, Brohi K, Dutton RP et al (2008) The coagulopathy of trauma: a review of mechanisms. J Trauma 65:748–754PubMedCrossRef Hess JR, Brohi K, Dutton RP et al (2008) The coagulopathy of trauma: a review of mechanisms. J Trauma 65:748–754PubMedCrossRef
14.
Zurück zum Zitat Hess JR, Dutton RB, Holcomb JB et al (2008) Giving plasma at a 1:1 ratio with red cells in resuscitation: who might benefit? Transfusion 48:1763–1765PubMedCrossRef Hess JR, Dutton RB, Holcomb JB et al (2008) Giving plasma at a 1:1 ratio with red cells in resuscitation: who might benefit? Transfusion 48:1763–1765PubMedCrossRef
15.
Zurück zum Zitat Hess JR, Lawson JH (2006) The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 60:S12–S19PubMedCrossRef Hess JR, Lawson JH (2006) The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 60:S12–S19PubMedCrossRef
16.
17.
Zurück zum Zitat Holcomb JB, Wade CE, Michalek JE et al (2008) Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 248:447–458PubMed Holcomb JB, Wade CE, Michalek JE et al (2008) Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 248:447–458PubMed
19.
Zurück zum Zitat Lier H, Kampe S, Schroder S (2007) Prerequisites of a functional haemostasis. What must be considered at the scene of an accident, in the emergency room and during an operation? Anaesthesist 56:239–251PubMedCrossRef Lier H, Kampe S, Schroder S (2007) Prerequisites of a functional haemostasis. What must be considered at the scene of an accident, in the emergency room and during an operation? Anaesthesist 56:239–251PubMedCrossRef
20.
Zurück zum Zitat Lier H, Krep H, Schochl H (2009) Coagulation management in the treatment of multiple trauma. Anaesthesist 58:1010–1026PubMedCrossRef Lier H, Krep H, Schochl H (2009) Coagulation management in the treatment of multiple trauma. Anaesthesist 58:1010–1026PubMedCrossRef
21.
Zurück zum Zitat Lier H, Krep H, Schroeder S et al (2008) Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 65:951–960PubMedCrossRef Lier H, Krep H, Schroeder S et al (2008) Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 65:951–960PubMedCrossRef
22.
Zurück zum Zitat Macleod JB, Lynn M, Mckenney MG et al (2003) Early coagulopathy predicts mortality in trauma. J Trauma 55:39–44PubMedCrossRef Macleod JB, Lynn M, Mckenney MG et al (2003) Early coagulopathy predicts mortality in trauma. J Trauma 55:39–44PubMedCrossRef
23.
Zurück zum Zitat Maegele M (2014) The coagulopathy of trauma. Eur J Trauma Emerg Surg 40:113–126CrossRef Maegele M (2014) The coagulopathy of trauma. Eur J Trauma Emerg Surg 40:113–126CrossRef
24.
Zurück zum Zitat Maegele M, Lefering R, Paffrath T et al (2008) Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. Vox Sang 95:112–119PubMedCrossRef Maegele M, Lefering R, Paffrath T et al (2008) Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. Vox Sang 95:112–119PubMedCrossRef
25.
Zurück zum Zitat Maegele M, Lefering R, Wafaisade A et al (2010) Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang 100:231–238PubMedCrossRef Maegele M, Lefering R, Wafaisade A et al (2010) Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang 100:231–238PubMedCrossRef
26.
Zurück zum Zitat Maegele M, Lefering R, Yucel N et al (2007) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 38:298–304PubMedCrossRef Maegele M, Lefering R, Yucel N et al (2007) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 38:298–304PubMedCrossRef
27.
Zurück zum Zitat Maegele M, Paffrath T, Bouillon B (2012) Acute traumatic coagulopathy in severe injury: incidence, risk stratification, and treatment options. Dtsch Arztebl Int 108:827–835 Maegele M, Paffrath T, Bouillon B (2012) Acute traumatic coagulopathy in severe injury: incidence, risk stratification, and treatment options. Dtsch Arztebl Int 108:827–835
28.
Zurück zum Zitat Mann KG, Butenas S, Brummel K (2003) The dynamics of thrombin formation. Arterioscler Thromb Vasc Biol 23:17–25PubMedCrossRef Mann KG, Butenas S, Brummel K (2003) The dynamics of thrombin formation. Arterioscler Thromb Vasc Biol 23:17–25PubMedCrossRef
29.
Zurück zum Zitat Nunez TC, Voskresensky IV, Dossett LA et al (2009) Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 66:346–352PubMedCrossRef Nunez TC, Voskresensky IV, Dossett LA et al (2009) Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 66:346–352PubMedCrossRef
31.
Zurück zum Zitat Sauaia A, Moore FA, Moore EE et al (1995) Epidemiology of trauma deaths: a reassessment. J Trauma 38:185–193PubMedCrossRef Sauaia A, Moore FA, Moore EE et al (1995) Epidemiology of trauma deaths: a reassessment. J Trauma 38:185–193PubMedCrossRef
32.
Zurück zum Zitat Shakur H, Roberts I, Bautista R et al (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376:23–32PubMedCrossRef Shakur H, Roberts I, Bautista R et al (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376:23–32PubMedCrossRef
33.
Zurück zum Zitat Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17:R76PubMedCentralPubMedCrossRef Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17:R76PubMedCentralPubMedCrossRef
34.
Zurück zum Zitat Spahn DR, Rossaint R (2005) Coagulopathy and blood component transfusion in trauma. Br J Anaesth 95:130–139PubMedCrossRef Spahn DR, Rossaint R (2005) Coagulopathy and blood component transfusion in trauma. Br J Anaesth 95:130–139PubMedCrossRef
35.
Zurück zum Zitat Wafaisade A, Wutzler S, Lefering R et al (2010) Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J 27:934–939PubMedCrossRef Wafaisade A, Wutzler S, Lefering R et al (2010) Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J 27:934–939PubMedCrossRef
36.
Zurück zum Zitat Weber CF, Adam EH, Meybohm P et al (2013) Management of extended blood loss and massive transfusion. Anasthesiol Intensivmed Notfallmed Schmerzther 48:314–317PubMedCrossRef Weber CF, Adam EH, Meybohm P et al (2013) Management of extended blood loss and massive transfusion. Anasthesiol Intensivmed Notfallmed Schmerzther 48:314–317PubMedCrossRef
37.
Zurück zum Zitat Yucel N, Lefering R, Maegele M et al (2006) Trauma Associated Severe Hemorrhage (TASH)-score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 60:1228–1236PubMedCrossRef Yucel N, Lefering R, Maegele M et al (2006) Trauma Associated Severe Hemorrhage (TASH)-score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 60:1228–1236PubMedCrossRef
Metadaten
Titel
Blutungen und Gerinnungsstörungen beim Polytrauma
Aktueller Stand der Diagnostik und des Managements bei traumaassoziierten Koagulopathien
verfasst von
PD Dr. S. Wutzler
M. Maegele
T. Lustenberger
F. Hildebrand
R. Lefering
M. Frink
I. Marzi
Die Sektion Trauma der DIVI
Publikationsdatum
01.11.2014
Verlag
Springer Berlin Heidelberg
Erschienen in
Notfall + Rettungsmedizin / Ausgabe 7/2014
Print ISSN: 1434-6222
Elektronische ISSN: 1436-0578
DOI
https://doi.org/10.1007/s10049-014-1863-6

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