Berndtson A E, Coimbra R
Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego, 200 West Arbor Drive, Mail Code 8896, San Diego, CA, 92103, USA.
Eur J Trauma Emerg Surg. 2014 Dec;40(6):657-69. doi: 10.1007/s00068-014-0404-9. Epub 2014 May 1.
As the population ages, an increasing number of trauma patients are taking antiplatelet and anticoagulant medications (ACAP) prior to their injuries. These medications increase their risk of hemorrhagic complications, particularly intracerebral hemorrhage. Clopidogrel and warfarin are common and their mechanisms well understood, but optimal reversal methods continue to evolve. The novel direct thrombin and factor Xa inhibitors are less well described and do not have existing antidotes.
This article reviews the relevant literature on traumatic outcomes with use of ACAP medications, as well as data on ideal reversal strategies. Suggested algorithms are introduced, and future research directions discussed.
Although they are beneficial in preventing clot formation, once bleeding occurs ACAP medications contribute to increased morbidity and mortality, particularly in geriatric patient populations. The efficacy of clopidogrel reversal with platelet transfusions and DDAVP remains unclear. Warfarin use is best treated with the algorithm-driven use of plasma, vitamin K, prothrombin complex concentrates (PCCs) and possibly recombinant factor VIIa depending upon specific patient and injury factors. Optimal treatment for direct thrombin and factor Xa inhibitors has yet to be developed, but PCCs are promising for rivaroxaban and apixaban while dabigatran is best treated with medication cessation and the possible addition of activated PCCs or hemodialysis.
New developments in reversal of the ACAP medications are promising, particularly PCCs for warfarin and the factor Xa inhibitors. Function assays and clear antidotes are needed for the thrombin and Xa inhibitors. Research on outcomes and appropriate treatments is actively ongoing.
随着人口老龄化，越来越多的创伤患者在受伤前正在服用抗血小板和抗凝药物（ACAP）。这些药物增加了他们发生出血并发症的风险，尤其是脑出血。氯吡格雷和华法林很常见，其作用机制也已为人熟知，但最佳的逆转方法仍在不断发展。新型直接凝血酶抑制剂和Xa因子抑制剂的相关描述较少，且尚无现有的解毒剂。
本文回顾了有关使用ACAP药物的创伤结局的相关文献，以及理想逆转策略的数据。介绍了建议的算法，并讨论了未来的研究方向。
尽管ACAP药物在预防血栓形成方面有益，但一旦发生出血，它们会导致发病率和死亡率增加，尤其是在老年患者群体中。血小板输注和去氨加压素逆转氯吡格雷的疗效仍不明确。华法林的使用最好根据特定的患者和损伤因素，通过算法驱动使用血浆、维生素K、凝血酶原复合物浓缩剂（PCC）以及可能的重组因子VIIa进行治疗。直接凝血酶抑制剂和Xa因子抑制剂的最佳治疗方法尚未开发，但PCC对利伐沙班和阿哌沙班有前景，而达比加群最好通过停药并可能加用活化PCC或血液透析进行治疗。
ACAP药物逆转方面的新进展很有前景，尤其是用于华法林和Xa因子抑制剂的PCC。凝血酶和Xa抑制剂需要功能测定和明确的解毒剂。关于结局和适当治疗的研究正在积极进行中。
