Traumaassoziierte Koagulopathie: Pathophysiologie und Therapie

Zusammenfassung

Die anhaltende unkontrollierte Blutung ist eine der führenden Todesursachen bei polytraumatisierten Patienten [1], [2], [3], [4], [5]. Hypoperfusion durch große Blutverluste führt zu Gewebeschäden, generalisierter Immunantwort sowie Aktivierung des Gerinnungssystems und damit zu einer traumaassoziierten Koagulopathie (TAK) [4], [5]. Durch eine adäquate, frühzeitige Behandlung der TAK können Morbidität und Mortalität signifikant reduziert werden.

Abstract

Persistent, uncontrolled bleeding after trauma is one of the leading causes of fatalities in patients with severe injuries. 40% of trauma deaths are associated with massive haemorrhage. Hypoperfusion due to major loss of blood volume leads to tissue damage. In combination with acidosis and hypothermia, a generalized immune response with activation of coagulation is triggered. This leads to trauma-induced coagulopathy. A suitable, early treatment might lead to a significant reduction in morbidity and mortality.

Schlüsselwörter

Traumaassoziierte Koagulopathie - Point-of-Care - Plasma - Faktorenkonzentrate - Schockraum

Key words

trauma-induced coagulopathy - point-of-care - plasma - coagulation factor concentrates - emergency room management

• Literatur

• 1 Khan S, Davenport R, Raza I. et al. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Intensive Care Med 2015; 41: 239-247
• 2 Campbell HE, Stokes EA, Bargo DN. et al. Quantifying the healthcare costs of treating severely bleeding major trauma patients: a national study for England. Crit Care 2015; 19: 276
• 3 Schöchl H, Nienaber U, Maegele M. et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011; 15: R83
• 4 Lord JM, Midwinter MJ, Chen YF. et al. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet 2014; 384: 1455-1465
• 5 Mutschler M, Paffrath T, Wölfl C. et al. The ATLS^® classification of hypovolaemic shock: A well established teaching tool on the edge?. Injury 2014; 45: S35-S38
• 6 Brohi K, Cohen MJ, Ganter MT. et al. Acute Coagulopathy of Trauma: Hypoperfusion Induces Systemic Anticoagulation and Hyperfibrinolysis. J Trauma 2008; 64: 1211-1217
• 7 Maegele M. Frequency, risk stratification and therapeutic management of acute post-traumatic coagulopathy. Vox Sanguinis 2009; 97: 39-49
• 8 Rossaint R, Bouillon B, Cerny V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20: 100
• 9 Stensballe J, Ulrich AG, Nilsson JC. et al. Resuscitation of Endotheliopathy and Bleeding in Thoracic Aortic Dissections: The VIPER-OCTA Randomized Clinical Pilot Trial. Anesth Analg 2018; 127: 920-927
• 10 Maegele M. Moderne Gerinnungstherapie beim blutenden Schwerverletzten: Faktorengabe nach „Point-of-care“. Med Klin Intensivmed Notfmed 2017;
• 11 Tauber H, Innerhofer P, Breitkopf R. et al. Prevalence and impact of abnormal ROTEM^® assays in severe blunt trauma: results of the “Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study”. Br J Anaesth 2011; 107: 378-387
• 12 Kragh JF, Walters TJ, Baer DG. et al. Survival With Emergency Tourniquet Use to Stop Bleeding in Major Limb Trauma. Ann Surg 2009; 249: 1-7
• 13 Moore HB, Moore EE, Chapman MP. et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet 2018; 392: 283-291
• 14 Annane D. Effects of Fluid Resuscitation With Colloids vs. Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock: The CRISTAL Randomized Trial. JAMA 2013; 310: 1809
• 15 Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; (02) CD000567
• 16 Roberts I, Shakur H, Coats T. et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013; 17: 1-79
• 17 Gayet-Ageron A, Prieto-Merino D, Ker K. et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2018; 391: 125-132
• 18 Ho KM, Leonard AD. Concentration-dependent effect of hypocalcaemia on mortality of patients with critical bleeding requiring massive transfusion: a cohort study. Anaesth Intensive Care 2011; 39: 46-54
• 19 Innerhofer P, Fries D, Mittermayr M. et al. Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-label, randomised trial. Lancet Haematol 2017; 4: e258-e271
• 20 Cothren CC, Moore EE, Hedegaard HB. et al. Epidemiology of Urban Trauma Deaths: A Comprehensive Reassessment 10 Years Later. World J Surg 2007; 31: 1507-1511
• 21 Dente CJ, Shaz BH, Nicholas JM. et al. Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol in a Civilian Level I Trauma Center. J Trauma 2009; 66: 1616-1624