Skip to main content
Erschienen in: Notfall + Rettungsmedizin 2/2015

01.03.2015 | Konzepte - Stellungnahmen - Leitlinien

Traumaassoziierte Gerinnungsstörung

Mechanismen, Risikoeinschätzung und aktuelle Leitlinien

verfasst von: A. Driessen, Prof. Dr. M. Maegele

Erschienen in: Notfall + Rettungsmedizin | Ausgabe 2/2015

Einloggen, um Zugang zu erhalten

Zusammenfassung

Problematik und Zielsetzung

Die führende Todesursache beim Trauma innerhalb der ersten 6 h ist die nicht kontrollierte Blutung. Einer von 4 Patienten weist bei Schockraumaufnahme eine Störung seiner Gerinnungsfunktion auf. Inflammation, Gewebehypoperfusion und Aktivierung neurohumoraler Faktoren werden als Treiber der Gerinnungsstörung angeschuldigt und führen über Endothelschädigung zu Hyperpermeabilität, Fibrinolyse und Autoheparinisierung. Die iatrogene Koagulopathie (IC) verstärkt durch Hämodilution, Azidose und Hypothermie („circulus vitiosus“) die primär bestehende Gerinnungsstörung.

Ergebnisse und Schlussfolgerungen

Ein Hauptproblem bleibt die frühe Risikostratifizierung. Standardlaborparameter bieten keine ausreichende Spezifität zur Detektion bereits bestehender Gerinnungsstörungen. Scoring-Systeme als Surrogate zur Vorhersage der Transfusionswahrscheinlichkeit wurden auf Grundlage retrospektiver Daten entwickelt und bislang nicht prospektiv validiert. Viskoelastische Testverfahren bilden die Dynamik und Nachhaltigkeit der Gerinnselbildung rasch ab. Die Therapie orientiert sich an den 2013 aktualisierten Leitlinien.
Literatur
1.
Zurück zum Zitat Brohi K, Cohen MJ, Davenport RA (2007) Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 13:680–685CrossRefPubMed Brohi K, Cohen MJ, Davenport RA (2007) Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 13:680–685CrossRefPubMed
2.
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 245:812–818CrossRefPubMedCentralPubMed Brohi K, Cohen MJ, Ganter MT et al (2007) Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 245:812–818CrossRefPubMedCentralPubMed
3.
Zurück zum Zitat Brohi K, Singh J, Heron M, Coats T (2003) Acute traumatic coagulopathy. J Trauma 54:1127–1130CrossRefPubMed Brohi K, Singh J, Heron M, Coats T (2003) Acute traumatic coagulopathy. J Trauma 54:1127–1130CrossRefPubMed
4.
Zurück zum Zitat Callum JL, Rizoli S (2012) Plasma transfusion for patients with severe hemorrhage: what is the evidence? Transfusion 52(Suppl 1):30S–37SCrossRefPubMed Callum JL, Rizoli S (2012) Plasma transfusion for patients with severe hemorrhage: what is the evidence? Transfusion 52(Suppl 1):30S–37SCrossRefPubMed
5.
Zurück zum Zitat Cotton BA, Faz G, Hatch QM et al (2011) Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma 71:407–414 (discussion 414–417)CrossRefPubMed Cotton BA, Faz G, Hatch QM et al (2011) Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma 71:407–414 (discussion 414–417)CrossRefPubMed
6.
Zurück zum Zitat Curry N, Stanworth S, Hopewell S et al (2011) Trauma-induced coagulopathy – a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev 25:217–231.e2CrossRefPubMed Curry N, Stanworth S, Hopewell S et al (2011) Trauma-induced coagulopathy – a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev 25:217–231.e2CrossRefPubMed
7.
Zurück zum Zitat Davenport R, Manson J, De’Ath H et al (2011) Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 39:2652–2658PubMedCentralPubMed Davenport R, Manson J, De’Ath H et al (2011) Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 39:2652–2658PubMedCentralPubMed
8.
Zurück zum Zitat Deras P, Villiet M, Manzanera J et al (2014) Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients. J Trauma Acute Care Surg 77:433–440CrossRefPubMed Deras P, Villiet M, Manzanera J et al (2014) Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients. J Trauma Acute Care Surg 77:433–440CrossRefPubMed
9.
Zurück zum Zitat Driessen A, Schäfer N, Albrecht V et al (2014) Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy. Eur J Trauma Emerg Surg 1–8 Driessen A, Schäfer N, Albrecht V et al (2014) Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy. Eur J Trauma Emerg Surg 1–8
10.
Zurück zum Zitat Engström M, Schött U, Romner B, Reinstrup P (2006) Acidosis impairs the coagulation: a thromboelastographic study. J Trauma 61:624–628. doi:10.1097/01.ta.0000226739.30655.75CrossRefPubMed Engström M, Schött U, Romner B, Reinstrup P (2006) Acidosis impairs the coagulation: a thromboelastographic study. J Trauma 61:624–628. doi:10.1097/01.ta.0000226739.30655.75CrossRefPubMed
11.
12.
Zurück zum Zitat Hess JR, Brohi K, Dutton RP et al (2008) The coagulopathy of trauma: a review of mechanisms. J Trauma 65:748–754CrossRefPubMed Hess JR, Brohi K, Dutton RP et al (2008) The coagulopathy of trauma: a review of mechanisms. J Trauma 65:748–754CrossRefPubMed
13.
Zurück zum Zitat Hess JR, Lindell AL, Stansbury LG et al (2009) The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center. Transfusion 49:34–39CrossRefPubMed Hess JR, Lindell AL, Stansbury LG et al (2009) The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center. Transfusion 49:34–39CrossRefPubMed
14.
Zurück zum Zitat Johansson PI, Stensballe J, Rasmussen LS, Ostrowski SR (2011) A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients. Ann Surg 254:194–200CrossRefPubMed Johansson PI, Stensballe J, Rasmussen LS, Ostrowski SR (2011) A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients. Ann Surg 254:194–200CrossRefPubMed
15.
Zurück zum Zitat Kermode JC, Zheng Q, Milner EP (1999) Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood 94:199–207PubMed Kermode JC, Zheng Q, Milner EP (1999) Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood 94:199–207PubMed
17.
Zurück zum Zitat Lackner CK, Burghofer K, Stolpe E et al (2007) Prognostic value of routine parameters and laboratory parameters after major trauma. A prospective preclinical-clinical study of air rescue patients. Unfallchirurg 110:307–319CrossRefPubMed Lackner CK, Burghofer K, Stolpe E et al (2007) Prognostic value of routine parameters and laboratory parameters after major trauma. A prospective preclinical-clinical study of air rescue patients. Unfallchirurg 110:307–319CrossRefPubMed
18.
Zurück zum Zitat Lowenstein CJ, Morrell CN, Yamakuchi M (2005) Regulation of Weibel-Palade body exocytosis. Trends Cardiovasc Med 15:302–308CrossRefPubMed Lowenstein CJ, Morrell CN, Yamakuchi M (2005) Regulation of Weibel-Palade body exocytosis. Trends Cardiovasc Med 15:302–308CrossRefPubMed
19.
Zurück zum Zitat MacLeod JBA, Cohn SM, Johnson EW, McKenney MG (2007) Trauma deaths in the first hour: are they all unsalvageable injuries? Am J Surg 193:195–199CrossRefPubMed MacLeod JBA, Cohn SM, Johnson EW, McKenney MG (2007) Trauma deaths in the first hour: are they all unsalvageable injuries? Am J Surg 193:195–199CrossRefPubMed
20.
Zurück zum Zitat Maegele M (o J) The coagulopathy of trauma M. Maegele. Eur J Trauma Emerg Surg 40:113–126 Maegele M (o J) The coagulopathy of trauma M. Maegele. Eur J Trauma Emerg Surg 40:113–126
21.
Zurück zum Zitat Maegele M, Brockamp T, Nienaber U et al (2012) Predictive models and algorithms for the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemotherapy 39:85–97CrossRef Maegele M, Brockamp T, Nienaber U et al (2012) Predictive models and algorithms for the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemotherapy 39:85–97CrossRef
22.
Zurück zum Zitat Maegele M, Lefering R, Wafaisade A et al (2011) 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 100:231–238CrossRefPubMed Maegele M, Lefering R, Wafaisade A et al (2011) 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 100:231–238CrossRefPubMed
23.
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 38:298–304CrossRefPubMed 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 38:298–304CrossRefPubMed
24.
Zurück zum Zitat Maegele M, Schöchl H, Cohen MJ (2013) An up-date on the coagulopathy of trauma. Shock. doi:10.1097/SHK.0000000000000088 Maegele M, Schöchl H, Cohen MJ (2013) An up-date on the coagulopathy of trauma. Shock. doi:10.1097/SHK.0000000000000088
25.
Zurück zum Zitat Maegele M, Spinella PC, Schöchl H (2012) The acute coagulopathy of trauma: mechanisms and tools for risk stratification. Shock 38:450–458CrossRefPubMed Maegele M, Spinella PC, Schöchl H (2012) The acute coagulopathy of trauma: mechanisms and tools for risk stratification. Shock 38:450–458CrossRefPubMed
26.
Zurück zum Zitat Martini WZ (2009) Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma 67:202–208 (discussion 208–209)CrossRefPubMed Martini WZ (2009) Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma 67:202–208 (discussion 208–209)CrossRefPubMed
27.
Zurück zum Zitat Meng ZH, Wolberg AS, Monroe DM, Hoffman M (2003) The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma 55:886–891CrossRefPubMed Meng ZH, Wolberg AS, Monroe DM, Hoffman M (2003) The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma 55:886–891CrossRefPubMed
28.
Zurück zum Zitat Mitra B, Rainer TH, Cameron PA (2012) Predicting massive blood transfusion using clinical scores post-trauma. Vox Sang 102:324–330CrossRefPubMed Mitra B, Rainer TH, Cameron PA (2012) Predicting massive blood transfusion using clinical scores post-trauma. Vox Sang 102:324–330CrossRefPubMed
29.
Zurück zum Zitat Monroe DM (2008) Modeling the action of factor VIIa in dilutional coagulopathy. Thromb Res 122(Suppl):S7–S10CrossRefPubMed Monroe DM (2008) Modeling the action of factor VIIa in dilutional coagulopathy. Thromb Res 122(Suppl):S7–S10CrossRefPubMed
30.
Zurück zum Zitat Murray CJ, Lopez AD (1997) Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 349:1269–1276CrossRefPubMed Murray CJ, Lopez AD (1997) Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 349:1269–1276CrossRefPubMed
31.
Zurück zum Zitat Nadler R, Gendler S, Benov A et al (2014) Tranexamic acid at the point of injury: the Israeli combined civilian and military experience. J Trauma Acute Care Surg 77:S146–S150. doi:10.1097/TA.0000000000000325CrossRefPubMed Nadler R, Gendler S, Benov A et al (2014) Tranexamic acid at the point of injury: the Israeli combined civilian and military experience. J Trauma Acute Care Surg 77:S146–S150. doi:10.1097/TA.0000000000000325CrossRefPubMed
32.
Zurück zum Zitat Nieuwdorp M, Meuwese MC, Vink H et al (2005) The endothelial glycocalyx: a potential barrier between health and vascular disease. Curr Opin Lipidol 16:507–511CrossRefPubMed Nieuwdorp M, Meuwese MC, Vink H et al (2005) The endothelial glycocalyx: a potential barrier between health and vascular disease. Curr Opin Lipidol 16:507–511CrossRefPubMed
33.
Zurück zum Zitat Niles SE, McLaughlin DF, Perkins JG et al (2008) Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma 64:1459–1463 (discussion 1463–1465). doi:10.1097/TA.0b013e318174e8bcCrossRefPubMed Niles SE, McLaughlin DF, Perkins JG et al (2008) Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma 64:1459–1463 (discussion 1463–1465). doi:10.1097/TA.0b013e318174e8bcCrossRefPubMed
34.
Zurück zum Zitat Ostrowski SR, Johansson PI (2012) Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg 73:60–66CrossRefPubMed Ostrowski SR, Johansson PI (2012) Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg 73:60–66CrossRefPubMed
35.
Zurück zum Zitat Patregnani JT, Borgman MA, Maegele M et al (2012) Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals. Pediatr Crit Care Med 13:273–277CrossRefPubMed Patregnani JT, Borgman MA, Maegele M et al (2012) Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals. Pediatr Crit Care Med 13:273–277CrossRefPubMed
37.
Zurück zum Zitat Ruchholtz S, Pehle B, Lewan U et al (2006) The emergency room transfusion score (ETS): prediction of blood transfusion requirement in initial resuscitation after severe trauma. Transfus Med 16:49–56CrossRefPubMed Ruchholtz S, Pehle B, Lewan U et al (2006) The emergency room transfusion score (ETS): prediction of blood transfusion requirement in initial resuscitation after severe trauma. Transfus Med 16:49–56CrossRefPubMed
39.
Zurück zum Zitat Schöchl H, Frietsch T, Pavelka M, Jámbor C (2009) Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 67:125–131CrossRefPubMed Schöchl H, Frietsch T, Pavelka M, Jámbor C (2009) Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 67:125–131CrossRefPubMed
40.
Zurück zum Zitat Schöchl H, Maegele M, Solomon C et al (2012) Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med 20:15CrossRefPubMedCentralPubMed Schöchl H, Maegele M, Solomon C et al (2012) Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med 20:15CrossRefPubMedCentralPubMed
41.
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 376:23–32CrossRefPubMed 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 376:23–32CrossRefPubMed
42.
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:R76CrossRefPubMedCentralPubMed Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17:R76CrossRefPubMedCentralPubMed
43.
Zurück zum Zitat Wafaisade A, Wyen H, Mutschler M et al (2014) Current practice in coagulation and transfusion therapy in multiple trauma patients: a German nation-wide online survey. Unfallchirurg 1–7 Wafaisade A, Wyen H, Mutschler M et al (2014) Current practice in coagulation and transfusion therapy in multiple trauma patients: a German nation-wide online survey. Unfallchirurg 1–7
44.
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 27:934–939CrossRefPubMed 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 27:934–939CrossRefPubMed
45.
Zurück zum Zitat Wolberg AS, Meng ZH, Monroe DM, Hoffman M (2004) A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 56:1221–1228CrossRefPubMed Wolberg AS, Meng ZH, Monroe DM, Hoffman M (2004) A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 56:1221–1228CrossRefPubMed
46.
Zurück zum Zitat Yücel 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 60:1228–1236 (discussion 1236–1237)CrossRefPubMed Yücel 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 60:1228–1236 (discussion 1236–1237)CrossRefPubMed
Metadaten
Titel
Traumaassoziierte Gerinnungsstörung
Mechanismen, Risikoeinschätzung und aktuelle Leitlinien
verfasst von
A. Driessen
Prof. Dr. M. Maegele
Publikationsdatum
01.03.2015
Verlag
Springer Berlin Heidelberg
Erschienen in
Notfall + Rettungsmedizin / Ausgabe 2/2015
Print ISSN: 1434-6222
Elektronische ISSN: 1436-0578
DOI
https://doi.org/10.1007/s10049-014-1972-2

Weitere Artikel der Ausgabe 2/2015

Notfall + Rettungsmedizin 2/2015 Zur Ausgabe