Zusammenfassung
Die akzidenzielle Hypothermie ist eine häufige Komplikation bei schwerverletzten Patienten. Risikofaktoren stellen die Kälteexposition am Unfallort sowie in der Klinik dar, die Infusion kalter Lösungen, ein bestehendes Schockgeschehen sowie die Verabreichung von Anästhetika, die die Fähigkeit der Thermoregulation beeinflussen. Im Gegensatz zu tierexperimentellen Studien zeigen klinische Studien und Erfahrungen, dass die akzidenzielle Hypothermie des Schwerverletzten mit einer erhöhten Komplikations- und Mortalitätsrate assoziiert ist. Dies führte zu der Prägung des Begriffes der tödlichen Trias, bestehend aus akzidenzieller Hypothermie, Verbrauchskoagulopathie und Azidose. Auf zellulärer Ebene bewirkt die Hypothermie eine verminderte Aktivität und Metabolisierungsrate der Zellen. Dies führt einerseits zu einem reduzierten Sauerstoffverbrauch der Zellen, was sich in der Therapie des Herz-Kreislauf-Stillstandes zu nutzen gemacht wird, andererseits werden gleichzeitig wichtige Enzymaktivitäten herunterreguliert. Hierbei ist im Rahmen der Schwerverletztenversorgung insbesondere die verminderte enzymatische Aktivität der Gerinnungskaskade von Bedeutung, da die hypothermieinduzierte Koagulopathie nicht durch Substitution von Gerinnungsfaktoren, sondern nur durch Wiedererwärmung behandelt werden kann. Deshalb müssen hypotherme, hämodynamisch instabile Schwerverletzte aggressiv wiedererwärmt werden.
Abstract
Accidental hypothermia is a common complication in severely injured patients. Risk factors include environmental exposure of the patient at the accident site or in the clinic, infusion of cold fluids, hemorrhagic shock and anesthetics which influence thermoregulation. In contrast to animal studies, human studies and clinical experiences have identified accidental hypothermia of the severely injured patient to be associated with increased complication and mortality rates. As a consequence, hypothermia together with acidosis and coagulopathy, have been coined the lethal triad in severely injured patients. On a cellular level hypothermia reduces cellular activity and metabolism resulting in reduced oxygen consumption, which is therapeutically used in patients following cardiac arrest. However, the activity of important enzymes, such as those of the coagulation pathway, is simultaneously down regulated. Hypothermia-induced coagulopathy, which is refractory to substitution of coagulation factors, is a major complication of hypothermia in traumatized patients. Therefore, hypothermic trauma patients with hemodynamic instability require aggressive rewarming.
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Kobbe, P., Lichte, P., Wellmann, M. et al. Bedeutung der Hypothermie in der Traumatologie. Unfallchirurg 112, 1055–1061 (2009). https://doi.org/10.1007/s00113-009-1711-1
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DOI: https://doi.org/10.1007/s00113-009-1711-1
Schlüsselwörter
- Hypothermie
- Polytrauma
- Koagulopathie
- Wiedererwärmung
- Systemisches inflammatorisches Response-Syndrom (SIRS)