Abstract
Objective
Polytraumatized patients present with defects of haemostasis that manifest clinically either by haemorrhage and/or thrombosis. During the initial, as well as during the later phases of treatment, clinicians should take into account the most recent developments in the understanding, in the evaluation of the risk, and in the prevention of haemorrhagic and thrombotic complications.
Source
A group of experts, convened by the “Groupe d’intérêt en hémostase périopératoire” (Perioperative Haemostasis Interest Group) during the Annual Meeting of the Association of Anaesthetists of Quebec, held a symposium to review and integrate recent developments on haemostatic complications associated with trauma.
Main findings
The normal haemostatic balance is strongly compromised by trauma and shock. The percentage of patients with a coagulopathy and surgically uncontrollable haemorrhage varies between 18 and 40%. Abnormal coagulation after trauma is of multifactorial origin. Coagulopathy secondary to haemodilution is no longer considered the main cause of haemorrhage. Disseminated intravascular coagulation (DIC) is often manifest in the traumatic context. One out of every three polytraumatized patient will develop a deep vein thrombosis despite the preventive measures available at present. Clinical or laboratory detection of venous thrombosis either lacks sensitivity (physical examination or ultrasonography), or cannot be performed serially (phlebography).
Conclusions
Prevention and treatment of disorders of haemostasis relies upon the rapid and effective treatment of shock associated with trauma. Prevention of thromboembolic complications is paramount, taking into account the evolving balance between the risk of haemorrhage and the risk of thrombosis.
Abstract
Objectif
Le polytraumatisé présente des altérations hémostatiques se manifestant cliniquement sous forme d’hémorragies et/ou de thromboses. L’anesthésiste, impliqué tant durant la période initiale que durant la phase plus tardive du traumatisme, doit tenir compte des récents développements dans la compréhension, l’évaluation du risque et dans la prévention des manifestations hémorragiques et thrombotiques.
Sources
Lors des Xle Journées Franco-Québécoises d’Anesthésie-Réanimation, le Groupe d’Intérêt en Hémostase Périopératoire (GIHP) a réuni un groupe d’experts qui s’est penché sur les risques hémostatiques du polytraumatisé afin d’intégrer les récentes tendances émergeant tant de la littérature médicale que de la pratique clinique.
Principales constatations
L’équilibre de la balance hémostatique est fortement compromis par le traumatisme et l’état de choc. La proportion de patients ayant une coagulopathie s’exprimant par un saignement chirurgicalement incontrôlable varie entre 18–40%. L’étiologie des anomalies de la coagulation survenant lors d’un traumatisme est multifactorielle. Le concept de coagulopathie de dilution n’est plus considéré comme étant le principal mécanisme menant à l’hémorragie, La coagulation intravasculaire disséminée (CIVD) se manifeste lors de nombreuses situations traumatiques. Un polytraumatisé sur trois développe une thrombose veineuse profonde (TVP) malgré les moyens de prévention actuellement disponibles. Le dépistage, tant clinique que para-clinique, de la thrombose veineuse est soit peu sensible (examen au chevet et ultrasonographie) ou inadéquat pour une application répétitive (phlébographie).
Conclusions
Le traitement rapide et efficace du choc fait partie intégrante de la prévention et du traitement des désordres de l’hémostase. Une prophylaxie de la maladie thromboembolique doit être proposée à tous les polytraumatisés en tenant compte des risques thrombotiques et hémorragiques.
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Guay, J., Ozier, Y., de Moerloose, P. et al. Le polytraumatisé et les anomalies de l’hémostase. Can J Anaesth 45, 683–691 (1998). https://doi.org/10.1007/BF03012101
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DOI: https://doi.org/10.1007/BF03012101