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Hypothermie et coagulopathie

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Intérêt et méthodes de prévention de la coagulopathie liée à l'hypothermie dans le cadre des hémorragies

Publié dans : Santé & Médecine
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Hypothermie et coagulopathie

  1. 1. Dr Arnaud Depil Duval - Urgences CH Evreux
  2. 2. QUELQUES RAPPELS Dr Arnaud Depil Duval - Urgences CH Evreux
  3. 3. Dr Arnaud Depil Duval - Urgences CH Evreux
  4. 4. Fréquence • 40 à 78% des traumatisés graves sont en hypothermie Dr Arnaud Depil Duval - Urgences CH Evreux Tazarourte K, Rouxel JMP, Leblanc PE, Goix L, Vigné B. Qualité de la prise en charge pré-hospitalière des traumatisés crâniens graves en Ile de France. Ann Fr Anesth Réanim 2000;19(suppl 1):312 Rousseau JM, Marsigny B, Cauchy E, Bonsignour JP. Hypothermie en traumatologie. Ann Fr Anesth Réanim 1997;16:885-94 Luna G.K, Maier R.V, Pavlin E.G. Incidence and effect of hypothermia in seriously injured patients. J Trauma, 1987;27,9:1014-18
  5. 5. Etiologies Diminution de la production de chaleur endocrinopathies facteurs carentiels Anomalies de la thermo- régulation système nerveux périphérique système nerveux central Augmentation des pertes de chaleur vasodilatation causes dermatologiques : brûlures, dermatite causes iatrogènes causes liées à l'environnement Causes diverses polytraumatisme, choc, états septiques bactériens, viraux ou parasitaires, insuffisance rénale chronique. Dr Arnaud Depil Duval - Urgences CH Evreux
  6. 6. Effets du froid Plaquettes • Dysfonction plaquettaire constante • Diminution agrégation Endothélium • Thromboses micro-vasculaires • Adhésion anormale des cellules sanguines Coagulation • Allongement des temps de coagulation • Diminution de l’activité fonctionnelle des facteurs Fibrinolyse • Activée entre 28 et 34°C Dr Arnaud Depil Duval - Urgences CH Evreux
  7. 7. Effets du froid • Coagulopathie = 4x plus de décès • 100% de décès si température <32°C Augmentation des besoins en facteurs Augmentation transfusion Mortalité accrue Dr Arnaud Depil Duval - Urgences CH Evreux Reynold BR. & al. Hypothermia in massive transfusion: have we been paying enough attention to it? J Trauma Acute Care Surgery. 2012 Aug;73(2):486-9
  8. 8. Sédation Dr Arnaud Depil Duval - Urgences CH Evreux Marcos Díaz, and Daniel E. Becker, Thermoregulation: Physiological and Clinical Considerations during Sedation and General Anesthesia. Anesth Prog. 2010 Spring; 57(1): 25–33. Langhelle A, Lockey D, Harris T, Davies G. Body temperature of trauma patients on admission to hospital: a comparison of anaesthetised and non-anaesthetised patients. Emerg Med J. 2012 Mar;29(3):239-42. Epub 2010 Oct 20 Hypothermie Hypotha lamus Vasodila tation Perte frisson • Température de la salle • Perte par convection (courant d’air) • Majoré par : – Propofol – Opioïdes
  9. 9. Exploration de la coagulopathie Dr Arnaud Depil Duval - Urgences CH Evreux • Test réalisés à 37°C • Coagulopathie fonctionnelle sous- estimée
  10. 10. Monitorer la température • Idéalement température centrale : – Rectale à 10cm de la marge anale – Oesophagienne (risque de trouble du rythme) • En continu Dr Arnaud Depil Duval - Urgences CH Evreux
  11. 11. RÉCHAUFFER Dr Arnaud Depil Duval - Urgences CH Evreux
  12. 12. Réchauffer • Réchauffement externe • After Drop • Vasodilatation périphérique • Choc distributif Dr Arnaud Depil Duval - Urgences CH Evreux
  13. 13. Réchauffement externe • Couverture de survie • Eviter la perte de chaleur • Couverture chauffante • Limiter la déperdition thermique en péri- opératoire • Commencer plutôt par chauffer la SAUV 28- 32°C Dr Arnaud Depil Duval - Urgences CH Evreux
  14. 14. Réchauffement interne • Réchauffement de l’air inspiré • Lavage gastrique, vésical chaud • Lavage péritonéal • Plus simple : réchauffer les solutés… Dr Arnaud Depil Duval - Urgences CH Evreux
  15. 15. Réchauffer les solutés • Pas fréquent aux urgences • Inconnu en SMUR • Recettes exotiques • Matériel adapté Dr Arnaud Depil Duval - Urgences CH Evreux
  16. 16. Réchauffer les solutés +0,33°C de température centrale 1L de soluté à 42°C • Petit rappel : – les solutés dans un service sont au mieux à 25°C, – Les PFC et CGR sont froids, – donc favorisent l’hypothermie… Dr Arnaud Depil Duval - Urgences CH Evreux
  17. 17. Réchauffeur adapté aux urgences SMUR • Compact • Simple • Sur batteries • Peu de matériels adaptés disponibles en France Dr Arnaud Depil Duval - Urgences CH Evreux
  18. 18. Méfiez-vous du froid! Dr Arnaud Depil Duval - Urgences CH Evreux

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