Hintergrund: Therapeutische Hypothermie mittels Ganzkörperkühlung kann das neurolgisch-kognitive Outcome nach Hirnschädigung verbessern, ist jedoch mit teilweise schwerwiegenden Komplikationen verbunden. Die selektive Hirnkühlung (SHK) stellt eine Alternative zur Ganzkörperkühlung dar. Verschiedenen Verfahren der SHK unterscheiden sich in ihren physiologischen Grundlagen. Fragestellung: Die direkte Kühlung des Schädels (eSHK) wurde mit der pharyngealen Kühlung (pSHK) bezüglich der Regulation des zerebralen Blutflusses (ZBF) in einem Tiermodell untersucht. Material und Methoden: 10 Sprague-Dawley Ratten wurde analgosediert und beatmet. Die Gehirntemperatur (TH) wurde mit einer Temperatursonde in den Basalganglien (4mm Tiefe) gemessen (Oxyflow®, Fa. Oxford Optronix, Oxford, UK). pSHK wurde durch eine im Pharynx applizierte und mit Eiswasser gekühlte Thermosonde realisiert. Nach Erreichen eines stabilen Temperaturtiefpunktes (TN) durch pSHK wurde die Kühlphase unterbrochen. Im Anschluss erfolgte durch passive Erwärmung eine Rückkehr von TH zur ursprünglichen Ausgangstemperatur. Danach wurde durch direkte Applikation eines kalten Luftstroms auf den Schädel der Prozess der eSHK durchgeführt. Die Körperkerntemperatur wurde während beider Teilexperimente mit einer Heizmatte stabil gehalten. ZBF wurde durch einen Laser-Doppler-Sonde (Oxyflow®, Fa. Oxford Optronix) in der gleichen Tiefe wie die Temperatur gemessen. Der ZBF vor der Kühlung wurde mit dem ZBF zum Zeitpunkt eines stabilen TN für beide Methoden verglichen. Ergebnisse: Während der pSHK sank der ZBF im Bereich der Basalganglien um 28% (SD±17). Dagegen nahm der ZBF während der eSHK um 15% (SD±22) zu (p<0,0001). Diskussion: In der Region der Basalganglien wird der ZBF während pSHK reduziert. Im Gegensatz zur pSHK zeigt der ZBF während einer externen Kühlung einen signifikanten Anstieg. Nach einem hypoxisch-ischämischen oder traumatischen Hirnschaden kann ein gesteigerter intrakranieller Druck auftreten. Möglicherweise ist eine Zunahme des ZBF im Fall eines gesteigerten Hirndrucks ungünstig, da eine weitere Drucksteigerung im Schädel resultieren kann.Die klinische Bedeutung der beschriebenen Unterschiede des ZBF bei pSHK und eSHK müssen daher insbesondere in Bezug auf die Hirndruckregulation weiter untersucht werden.
INTRODUCTION Female sex may provide a survival benefit after trauma, possibly attributable to protective effects of estrogen. This study aimed to compare markers of coagulation between male and female trauma patients across different ages. METHODS Secondary analysis of a prospective cohort study that was conducted at six trauma centers. Trauma patients presenting with full trauma team activation were eligible for inclusion. Patients with a penetrating trauma or traumatic brain injury were excluded. Upon hospital arrival, blood was drawn for measurement of endothelial and coagulation markers and for rotational thromboelastometry measurement. Trauma patients were divided into four categories: males younger than 45 years, males 45 years or older, females younger than 45 years, and females 45 years or older. In a sensitivity analysis, patients between 45 and 55 years old were excluded to control for menopausal transitioning. Groups were compared with a Kruskal-Wallis test with Bonferroni correction. A logistic regression was performed to assess whether the independent effect of sex and age on mortality. RESULTS A total of 1,345 patients were available for analysis. Compared with the other groups, mortality was highest in females 45 years or older, albeit not independent from injury severity and shock. In the group of females 45 years or older, there was increased fibrinolysis, demonstrated by increased levels of plasmin-antiplasmin complexes with a concomitant decrease in α2-antiplasmin. Also, a modest decrease in coagulation factors II and X was observed. Fibrinogen levels were comparable between groups. The sensitivity analysis in 1,104 patients demonstrated an independent relationship between female sex, age 55 years or older, and mortality. Rotational thromboelastometry profiles did not reflect the changes in coagulation tests. CONCLUSION Female trauma patients past their reproductive age have an increased risk of mortality compared with younger females and males, associated with augmented fibrinolysis and clotting factor consumption. Rotational thromboelastometry parameters did not reflect coagulation differences between groups. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Abstract Background Trauma-induced coagulopathy in traumatic brain injury (TBI) remains associated with high rates of complications, unfavorable outcomes, and mortality. The underlying mechanisms are largely unknown. Embedded in the prospective multinational Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, coagulation profiles beyond standard conventional coagulation assays were assessed in patients with isolated TBI within the very early hours of injury. Methods Results from blood samples (citrate/EDTA) obtained on hospital admission were matched with clinical and routine laboratory data of patients with TBI captured in the CENTER-TBI central database. To minimize confounding factors, patients with strictly isolated TBI (iTBI) ( n = 88) were selected and stratified for coagulopathy by routine international normalized ratio (INR): (1) INR < 1.2 and (2) INR ≥ 1.2. An INR > 1.2 has been well adopted over time as a threshold to define trauma-related coagulopathy in general trauma populations. The following parameters were evaluated: quick’s value, activated partial thromboplastin time, fibrinogen, thrombin time, antithrombin, coagulation factor activity of factors V, VIII, IX, and XIII, protein C and S, plasminogen, D-dimer, fibrinolysis-regulating parameters (thrombin activatable fibrinolysis inhibitor, plasminogen activator inhibitor 1, antiplasmin), thrombin generation, and fibrin monomers. Results Patients with iTBI with INR ≥ 1.2 ( n = 16) had a high incidence of progressive intracranial hemorrhage associated with increased mortality and unfavorable outcome compared with patients with INR < 1.2 ( n = 72). Activity of coagulation factors V, VIII, IX, and XIII dropped on average by 15–20% between the groups whereas protein C and S levels dropped by 20%. With an elevated INR, thrombin generation decreased, as reflected by lower peak height and endogenous thrombin potential (ETP), whereas the amount of fibrin monomers increased. Plasminogen activity significantly decreased from 89% in patients with INR < 1.2 to 76% in patients with INR ≥ 1.2. Moreover, D-dimer levels significantly increased from a mean of 943 mg/L in patients with INR < 1.2 to 1,301 mg/L in patients with INR ≥ 1.2. Conclusions This more in-depth analysis beyond routine conventional coagulation assays suggests a counterbalanced regulation of coagulation and fibrinolysis in patients with iTBI with hemostatic abnormalities. We observed distinct patterns involving key pathways of the highly complex and dynamic coagulation system that offer windows of opportunity for further research. Whether the changes observed on factor levels may be relevant and explain the worse outcome or the more severe brain injuries by themselves remains speculative.
Neurocognitive problems associated with posttraumatic stress disorder (PTSD) can interact with impairment resulting from traumatic brain injury (TBI).We aimed to identify neurocognitive problems associated with probable PTSD following TBI in a civilian sample.The study is part of the CENTER-TBI project (Collaborative European Neurotrauma Effectiveness Research) that aims to better characterize TBI. For this cross-sectional study, we included patients of all severities aged over 15, and a Glasgow Outcome Score Extended (GOSE) above 3. Participants were assessed at six months post-injury on the PTSD Checklist-5 (PCL-5), the Trail Making Test (TMT), the Rey Auditory Verbal Learning Test (RAVLT) and the Cambridge Neuropsychological Test Automated Battery (CANTAB). Primary analysis was a complete case analysis. Regression analyses were performed to investigate the association between the PCL-5 and cognition.Of the 1134 participants included in the complete case analysis, 13.5% screened positive for PTSD. Probable PTSD was significantly associated with higher TMT-(B-A) (OR = 1.35, 95% CI: 1.14-1.60, p < .001) and lower RAVLT-delayed recall scores (OR = 0.74, 95% CI: 0.61-0.91, p = .004) after controlling for age, sex, psychiatric history, baseline Glasgow Coma Scale and education.Poorer performance on cognitive tests assessing task switching and, to a lesser extent, delayed verbal recall is associated with probable PTSD in civilians who have suffered TBI.
Liebe Lesende, in unserem Arbeitsalltag begegnen uns eine Vielzahl verschiedener Patient*innen. Was diese verbindet, sind ihre Einschränkungen der oberen Extremität, auf die wir als medizinische und therapeutische Expert*innen spezialisiert sind. Trotzdem sollten die physischen Verletzungen selten isoliert betrachtet werden, da die Hand keine Maschine ist, die allein durch eine rein funktionelle Behandlung „repariert“ und wieder zum Einsatz gebracht werden kann. Der Mensch, der hinter einer Diagnose steht, wirkt mit allem, was ihn ausmacht, bei seinem Heilungsprozess mit. Mit dieser Ausgabe wollen wir Ihnen ein wichtiges Thema näherbringen, das zur täglichen handtherapeutischen Praxis gehört: psychologische Aspekte bei der Arbeit mit Patient*innen.
This review presents a synopsis of best current knowledge with reference to the updated German and European guidelines and recommendations on the management of severe trauma hemorrhage and trauma-induced coagulopathy as well as a viscoelastic-based treatment algorithm based upon international expert consensus to trigger the administration of hemostatic agents and blood products.Uncontrolled hemorrhage and trauma-induced coagulopathy are the major causes for preventable death after trauma and early detection and aggressive management have been associated with improved outcomes. However, best practice to treat this newly defined entity is still under debate. In the acute phase, the clinical management usually follows the 'Damage Control Resuscitation' concept, which advocates the empiric administration of blood products in predefined and fixed ratios. As an alternative, several European but also a few US trauma centers have instituted the concept of 'Goal-directed Coagulation Therapy' based upon results obtained from early point-of-care viscoelastic testing.Current guidelines urge for the implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome.
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