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Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement

Wiegele M, Schöchl H, Haushofer A, Ortler M, Leitgeb J, Kwasny O, Beer R, Ay C, Schaden E. Crit Care 2019: 23:62

Kommentar Dr. M. Wiegele et al:

Im Falle eines Schädelhirntraumas stellt die (vermutete) Einnahme oraler Antikoagulantien betreuende Mediziner/-innen vor große Herausforderungen hinsichtlich Diagnostik, Reversierung/Therapie und Wiederbeginn der gerinnungshemmenden Dauermedikation. In Ermangelung evidenzbasierter Daten entschieden die betreuenden Teams bisher weitgehend individuell.

Um dieses Anleitungsvakuum zu füllen, lud die AGPG österreichische Expert/-innen aller betreuenden Disziplinen ein, gemeinsame Handlungsempfehlungen zu erstellen. Die Inhalte wurden anhand konkreter, klinischer Fragestellungen bearbeitet und im Februar 2019 im Critical Care (IF 6, 5) publiziert. Unter oben stehendem link steht das Paper gratis zum Download zur Verfügung.

Prähospitale FFP-Gabe bei Trauma?

Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326

In the PAMPer trial, prehospital low-dose plasma appeared beneficial for trauma patients.1 Mortality rates were 23% in the plasma group and 33% in the standard care group, while median injury severity scores (ISS) were 21 and 22, respectively. In contrast, a similar study by Moore et al. showed no survival benefit with prehospital plasma.2  In the Moore et al. study, and in the RETIC study of coagulation factor concentrates in trauma, mortality rates (4–15%) were lower than in PAMPer, despite higher ISS (27–35). 2,3  These findings raise questions regarding quality of care in PAMPer.

Prehospital plasma had no significant impact on TEG parameters in the PAMPer trial. A statistically significant between-group difference in prothrombin-time ratio was observed but, because median values were numerically similar (1.2 vs. 1.3), the clinical significance is questionable. Trauma patients may not require increased INR4 and, in any case, therapeutic plasma is acknowledged to have limited effectiveness in this regard. 5 The lower mortality in the plasma group is more likely attributable to increased circulation volume than improved coagulation.

References

  1. Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326.
  2. Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018 Jul 28;392(10144):283-291.
  3. Innerhofer P, Fries D, Mittermayr M,  et al. Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-label, randomised trial. Lancet Haematol. 2017 Jun;4(6):e258-e271..
  4. Dunbar NM, Chandler WL. Thrombin generation in trauma patients. Transfusion. 2009 Dec;49(12):2652-60.
  5. Holland LL, Foster TM, Marlar RA, et al. Fresh frozen plasma is ineffective for correcting minimally elevated international normalized ratios. Transfusion. 2005 Jul;45(7):1234-5.

Letzte Aktualisierung am 08.04.2019

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