多重創傷病人復甦策略的新趨勢 - tma.tw

1 / 40% (advanced trauma life support, ATLS) (postinjury coagulopathy) 1/3 (abbreviated surgical procedures (1) A B C D E A (Airway) B (Breath) C (Circulation) D (Disability) E (Exposure) 24 1.)

2 2. 3. 4. (delayed primary surgery) 1. 2. 3. ( 5000mL) 80% (nonresponders) ( l e t h a l t r i a d ) ( m e t a b o l i c a c i d os i s ) ( h y p o t h e r m i a ) (coagulopathy) 1. (life-saving surgery) 2.

3 (salvage surgery) 3. 4. (definitive surgery) (1) (2) (3) (4) damage control orthopaedics(DCO) 19019182011, , (permissive hypotension) (1) ( 2 ) ( 3 ) INR(international normalized r a t i o ) a P T T rapid thromboelastography ( r- T E G ) (2,3) r-TEG anti-fibrinolytics (hypertonic saline, HTS)HTS HTS (4)

4 HTS 30% (Hb) TRICC trial (Hb 7g/dL) Hb 10g/dL (5) Hb 7-10g/dL ( f r e s h f r o z e n p l a s m a , FFP) INR FFP:RBC=1:1 ( ) 1:1 (6) FFP:RBC 1:2-1:3(7) 100,000/uL :RBC=1:5 FFP:RBC: =1:1:1 (8) f i b r i n o g e n 1 g / L f i b r i n o g e n c o n c e n t r a t e ( 3 - 4 g ) cryoprecipitate (50mg/Kg 15-20units)(9) f i b r i n o g e n ( R B C 0.)

5 2 g f i b r i n o g e n ) ( > 0 . 2 g ) (10) C R A S H 2 t r i a l (antifibrinolytics) (11) XIII(activated factor XIII) VII(activated factor VII) (12,13) (massive transfusion) 24 20 (1) (2) (3) (4) 19019192011, , 1/3 1/5 (14) (hemoglobin) r-TEG 1.

6 Stahel PF, Smith WR, Moore EE: Current trends in resuscitation strategy for the multiply injured patient. Int J Care Injured 2009; 40(S4): Kashuk JL, Moore EE, Le T, et al. : Noncitrated whole blood is optimal for evaluation of postinjury coagulopathy with point-of-care rapid thrombelastography. J Surg Res 2009; 156 Salooja N, Perry DJ: Thrombelastography. Blood Coagul Fibrinolysis 2001; 12 Ciesla DJ, Moore EE, Biffl WL, et al. : Hypertonic saline attenuation of the neutrophil cytotoxic response is reversed upon restoration of normotonicity and reestablished by repeated hypertonic challenge. Surgery 2001; 129 McIntyre L, Hebert PC, Wells G, et al.: Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients?

7 J Trauma 2004; 57 Scalea TM, Bochicchio KM, Lumpkins K, et al. : Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients. Ann Surg 2008; 248 Kashuk JL, Moore EE, Johnson JL, et al.: Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer? J Trauma 2008; 65 Gunter OL, Jr., Au BK, Isbell JM, et al.:Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma 2008; 65 Spahn DR, Cerny V, Coats TJ, et al.: Management of bleeding following major trauma: a European guideline. Crit Care 2007; 11 Stinger HK, Spinella PC, Perkins JG, et al.

8 : The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma 2008; 64 Roberts I: The CRASH-2 trial of an antifibrinolytic agent in traumatic haemorrhage: an international collaboration. Indian J Med Res 2007; 125 Boffard KD, Riou B, Warren B, et al.: Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma 2005; 59 Vincent JL, Artigas A, Petersen LC, et al. : A multicenter, randomized, double-blind, placebo-controlled, dose escalation trial assessing safety and efficacy of active site inactivated recombinant factor VIIa in subjects with acute lung injury or acute respiratory distress syndrome.

9 Crit Care Med 2009; 37 Hoyt DB, Dutton RP, Hauser CJ, et al.: Management of coagulopathy in the patients with multiple injuries: results from an international survey of clinical practice. J Trauma 2008; 65.