Gerinnungsmanagement bei Polytrauma

Zusammenfassung

Bei der Therapie traumabedingter Koagulopathien sind zunächst die Hypothermie und Azidose aggressiv zu behandeln. Bereits im Schockraum ist bei polytraumatisierten Patienten häufig ein Fibrinogenmangel nachweisbar, daneben führen infundierte Kolloide zusätzlich zu Fibrinpolymerisationsstörungen. Der frühe Einsatz von Fibrinogen scheint deshalb gerechtfertigt. Mit PPSB und/oder Frischplasma können depletierte Gerinnungsfaktoren substituiert werden, angesichts des Infektionsrisikos ist bei der Gabe von Thrombozytenkonzentraten Zurückhaltung angezeigt. Das Potenzial hämostatischer Medikamente (z. B. Antifibrinolytika und DDAVP) ist für diese Indikation nur durch wenige Studien belegt, kann im Einzelfall allerdings sehr hilfreich sein. Die Gabe von rekombinantem FVIIa erreichte in einer randomisierten, kontrollierten Studie keine nachhaltige Verbesserung des Outcomes von Traumapatienten. Gleichzeitiges Anheben der Gerinnungsinhibitoren (Antithrombin) wird diskutiert, erscheint aber in der akuten Phase einer lebensbedrohlichen Blutung nicht sinnvoll.

Summary

In trauma associated coagulopathy, the initial treatment consists of hypothermia and acidosis have to be treated aggressively. Already in in the emergency room, fibrinogen deficiency can be detected frequently, in addition, colloids interfere with fibrin polymerisation. Under these aspects, the early administration of fibrinogen seems to be justified. Depleted coagulation factors can be substituted with PPSB and/or fresh frozen plasma, while in view of a risk of infection, retaining administration of platelet concentrates is indicated. The potential of using haemostatic agents like antifibrinolytics and DDAVP for this indication is only supported by few studies, although in individual cases it may be very helpful. The administration of recombinant FVIIa could not achieve sustainable amelioration of the outcome of trauma patients in a randomised controlled trial. Raising inhibitors of coagulation (antithrombin) simultaneously to antihaemorragic therapy is being discussed, but seems not reasonable in the acute phase of a life-threatening haemorrage.

Schlüsselwörter

Polytrauma - Koagulopathie - Gerinnungsmanagement

Keywords

Polytrauma - coagulopathy - coagulation management

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