Der Anaesthesist
-
Hemorrhage after traumatic injury results in coagulopathy which only worsens the situation. This coagulopathy is caused by depletion and dilution of clotting factors and platelets, increased fibrinolytic activity, hypothermia, metabolic changes and anemia. The effect of synthetic colloids used for compensating the blood loss, further aggravates the situation through their specific action on the hemostatic system. ⋯ Administration of fresh frozen plasma (FFP), platelet concentrates and antifibrinolytic agents is essential for restoring the impaired coagulation system in trauma patients. Clotting factor concentrates should be administered if coagulopathy is based on diagnosed depletion of clotting factors, if FFP is not available and if transfusion of FFP is insufficient to treat the coagulopathy. Recombined FVIIa is frequently employed during severe bleeding which could not be treated by conventional methods but the results of on-going clinical trials are not yet available.
-
Cricothyrotomy is a very invasive technique to secure the airway in an emergency but is irreplacable when less invasive techniques fail or cannot be instigated under the prevailing circumstances. Various techniques have been reported which can be subdivided into anatomical-surgical preparation or puncture techniques. ⋯ Training for each procedure can be carried out in intensive care departments, and using autopsy material or a manekin. Various methods of cricothyrotomy will be discussed here, and additionally an anatomical preparation and two puncture techniques will be demonstrated in detail.
-
The main diagnostic tool for the preoperative identification of patients with an increased risk of bleeding or thrombosis is the patient history. Laboratory diagnostics should only be performed if a bleeding diathesis is suspected from patient history or clinical symptoms of bleeding, or if an adequate patient history cannot be performed. Measurement of prothrombin time, aPTT, or bleeding time as a general preoperative screening procedure is neither cost-effective nor efficient for the identification of patients with increased bleeding risk. ⋯ In some cases, patients should be referred to a specialized coagulation clinic for further diagnostics and treatment planning. Preoperative laboratory diagnostics for thrombophilia are not necessary in most cases. The decision for intensified antithrombotic measures is made according to patient history and the postoperative clinical course.
-
Review
[Evidence-based intensive care treatment of intracranial hypertension after traumatic brain injury].
Traumatic brain injury (TBI) occurs frequently and is associated with a poor prognosis. Severe TBI results in substantial disability or death in more than 40% of cases. ⋯ In addition to surgical approaches, various conservative treatment options exist, such as the use of osmodiuretics, barbiturates, or corticosteroids, hyperventilation as well as induced therapeutic hypothermia. This review analyzes these treatment options and the therapeutic goals of lowering intracranial pressure (ICP) in patients after TBI using evidence-based criteria, and provides recommendations for clinical practice.
-
In an unprotected airway during cardiopulmonary resuscitation, two ventilations with an inspiratory time of 2 s after 15 chest compressions are recommended. Therefore, approximately 30% of the resuscitation attempt is spent on ventilation. Since survival rates did not decrease sharply when minute ventilation levels were relatively low, and uninterrupted chest compressions with a constant rate of approximately 100/min have been shown to be lifesaving, it may be beneficial to decrease the time spent on ventilation and instead, increase the time for chest compressions. ⋯ In this model of a simulated, unprotected airway, a reduction of inspiratory time from 2 to 1 s resulted in a significant increase of peak airway pressure, while lung tidal volumes and stomach inflation volumes were statistically different but clinically comparable.