Gerinnungsmanagement beim Polytrauma

Abstract

More than 25% of polytraumatized patients present in the emergency department with a coagulopathy which results in a 4-fold increase in mortality. The detection of microvascular bleeding is the major clinical indicator. Measurement of fibrinogen, activated partial thromboplastin time and prothrombin time as well as thrombelastometry are required. A prerequisite for the substitution of coagulation factors and platelets is an immediate surgical control of bleeding and correction of hypothermia, acidosis and hypocalcemia. The goals for platelet count, fibrinogen, PT and aPTT are well established. The use of an algorithm for transfusion and coagulation management results in optimized therapy and improved outcome. Substituted coagulation products are only effective if hyperfibrinolysis has been corrected before. The administration of fibrinogen corrects the coagulation factor that is critically reduced earliest, improves global coagulation tests and reduced mortality in some studies. The dose required (3-5 g) can be calculated by a formula. Fresh frozen plasma is given in a 1:1 ratio to red blood cells or at least 20-40 ml/kg body weight. A clear advantage for survival has not yet been shown and some of the risks include insufficient substitution of fibrinogen and transfusion-related acute lung injury. Goals for the administration of platelet concentrates depend on the acuity of bleeding, injury pattern (e.g. head trauma) and clinical signs of microvascular bleeding. Factor VIIa remains an off-label rescue therapy if bleeding persists despite optimization of preconditions and specific coagulation management.