Trimmel H, Herzer G, Schöchl H, Voelckel W G
Abteilung für Anästhesie, Notfall- und Allgemeine Intensivmedizin und Karl-Landsteiner Institut für Notfallmedizin, Landesklinikum Wiener Neustadt, Wien, Österreich.
ÖAMTC Flugrettung, Wien, Österreich.
Unfallchirurg. 2017 Sep;120(9):739-744. doi: 10.1007/s00113-017-0344-z.
Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.
创伤性脑损伤（TBI）以及因出血失控导致的失血性休克是严重创伤后死亡的主要原因。多发伤且合并TBI的患者死亡率要高出三倍。已知会损害TBI后预后的因素，即低血压、低氧血症、高碳酸血症、酸中毒、凝血功能障碍和体温过低，会因脑外损伤的范围和严重程度而加重。TBI重症监护的主要措施，至少在短期内，可能与多发伤患者的创伤护理理念相矛盾。特别是，在出血无法控制的情况下实现血压正常、在创伤性肺损伤中维持正常碳酸血症以及预防血栓栓塞都容易引发讨论。由于正常血压值的定义仍存在不确定性，以脑灌注压为导向的心血管管理至关重要。相比之下，毫无疑问，早期目标导向的凝血管理可改善TBI和多发伤患者的预后。后续手术干预的时机必须基于TBI病理的发展情况；因此，对合并TBI的多发伤患者进行重症监护需要重症监护医生和创伤外科医生持续密切合作，以便实现个体化的患者护理。
