Meißner Andreas, Schlenke Peter
Klinik für Anästhesie, Intensiv-und Notfallmedizin, Schmerztherapie und Palliativmedizin, Klinikum Stadt Soest, Germany.
Transfus Med Hemother. 2012 Apr;39(2):73-84. doi: 10.1159/000337250. Epub 2012 Mar 12.
Massive bleeding in trauma patients is a serious challenge for all clinicians, and an interdisciplinary diagnostic and therapeutic approach is warranted within a limited time frame. Massive transfusion usually is defined as the transfusion of more than 10 units of packed red blood cells (RBCs) within 24 h or a corresponding blood loss of more than 1- to 1.5-fold of the body's entire blood volume. Especially male trauma patients experience this life-threatening condition within their productive years of life. An important parameter for clinical outcome is to succeed in stopping the bleeding preferentially within the first 12 h of hospital admission. Additional coagulopathy in the initial phase is induced by trauma itself and aggravated by consumption and dilution of clotting factors. Although different aspects have to be taken into consideration when viewing at bleedings induced by trauma compared to those caused by major surgery, the basic strategy is similar. Here, we will focus on trauma-induced massive hemorrhage. Currently there are no definite, worldwide accepted algorithms for blood transfusion and strategies for optimal coagulation management. There is increasing evidence that a higher ratio of plasma and RBCs (e.g. 1:1) endorsed by platelet transfusion might result in a superior survival of patients at risk for trauma-induced coagulopathy. Several strategies have been evolved in the military environment, although not all strategies should be transferred unproven to civilian practice, e.g. the transfusion of whole blood. Several agents have been proposed to support the restoration of coagulation. Some have been used for years without any doubt on their benefit-to-risk profile, whereas great enthusiasm of other products has been discouraged by inefficacy in terms of blood transfusion requirements and mortality or significant severe side effects. This review surveys current literature on fluid resuscitation, blood transfusion, and hemostatic agents currently used during massive hemorrhage in order to optimize patients' blood and coagulation management in emergency medical aid.
创伤患者的大出血对所有临床医生来说都是一项严峻挑战，因此需要在有限时间内采取多学科诊断和治疗方法。大量输血通常定义为在24小时内输注超过10单位的浓缩红细胞（RBC），或相当于失血超过全身血容量的1至1.5倍。尤其是男性创伤患者在其生育年龄段会遭遇这种危及生命的情况。临床结果的一个重要参数是在入院后的前12小时内优先成功止血。初始阶段的额外凝血病由创伤本身诱发，并因凝血因子的消耗和稀释而加重。尽管与大手术引起的出血相比，在看待创伤引起的出血时需要考虑不同方面，但基本策略是相似的。在此，我们将重点关注创伤性大出血。目前尚无明确的、被全球广泛接受的输血算法和最佳凝血管理策略。越来越多的证据表明，血小板输注支持下的血浆与红细胞更高比例（如1:1）可能会提高创伤性凝血病风险患者的生存率。在军事环境中已经发展出了几种策略，尽管并非所有策略都应未经证实就应用于 civilian practice，例如输注全血。已经提出了几种药物来支持凝血功能的恢复。有些药物已经使用多年，其利弊关系毋庸置疑，而其他产品尽管在输血需求减少和死亡率方面无效，或者存在严重的副作用，但仍受到极大关注。这篇综述调查了目前关于大出血期间液体复苏、输血和止血药物的文献，以便在紧急医疗救助中优化患者的血液和凝血管理。
