{"id":433,"date":"2022-07-19T14:24:08","date_gmt":"2022-07-19T11:24:08","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=433"},"modified":"2022-07-19T14:24:08","modified_gmt":"2022-07-19T11:24:08","slug":"yasli-hastada-kafa-travmasi-hangi-noktalarda-hata-yapiyoruz","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-hastada-kafa-travmasi-hangi-noktalarda-hata-yapiyoruz\/","title":{"rendered":"Ya\u015fl\u0131 Hastada Kafa Travmas\u0131: \u201cHangi Noktalarda Hata Yap\u0131yoruz?\u201d"},"content":{"rendered":"

Kafa travmas\u0131, ya\u015fl\u0131 hastalar aras\u0131nda \u00f6nde gelen morbidite ve mortalite nedenidir. Travmatik yaralanmalar sonras\u0131 ciddi yaralanma riskini art\u0131ran \u00e7ok say\u0131da kronik t\u0131bbi duruma sahip olma e\u011filiminde olan ya\u015fl\u0131 hastalarda, kafa travmas\u0131 sonras\u0131 \u00f6l\u00fcm veya uzun s\u00fcreli bak\u0131ma ihtiya\u00e7 duyma olas\u0131l\u0131klar\u0131 gen\u00e7 yeti\u015fkinlere g\u00f6re \u00e7ok daha fazlad\u0131r (1). O\u0308zellikle 75 yas\u0327\u0131n u\u0308zerindeki hastalar, Travmatik Beyin Hasar\u0131 (TBH) ile ilis\u0327kili hastaneye yat\u0131s\u0327 ve o\u0308lu\u0308m oranlar\u0131na bak\u0131ld\u0131\u011f\u0131nda, en riskli hasta gurubunu olu\u015fturmaktad\u0131r (2).<\/p>\n

Kafa travmas\u0131 nedeni ile ba\u015fvuran ileri ya\u015ftaki hastalarda erken tan\u0131 ve m\u00fcdahale, TBH ile ili\u015fkili tehlikeleri azaltmak i\u00e7in kritik \u00f6neme sahiptir. Bu hastalarda, acil servis doktorunun kar\u015f\u0131la\u015ft\u0131\u011f\u0131 en b\u00fcy\u00fck zorluk, kafa travmas\u0131 olan hangi hastalar\u0131n akut travmatik kafa i\u00e7i yaralanmas\u0131 oldu\u011funu ve hangi hastalar\u0131n g\u00fcvenli bir \u015fekilde eve g\u00f6nderilebilece\u011fini belirlemektir. Bu yaz\u0131da, kafa travmas\u0131 olan ya\u015fl\u0131 hastalarda g\u00f6r\u00fclen farkl\u0131l\u0131klar ve bu farkl\u0131l\u0131klar\u0131n neden oldu\u011fu zorluklar\u0131n acil servis y\u00f6netimi anlat\u0131lacakt\u0131r.<\/p>\n

Ya\u015flanman\u0131n Kafa Travmas\u0131 \u00dczerine Etkileri<\/strong><\/p>\n

Ya\u015flanmaya e\u015flik eden bir dizi anatomik ve fizyolojik de\u011fi\u015fiklik, geriatrik travma hastas\u0131n\u0131n daha ciddi yaralanmas\u0131na ve \u00f6l\u00fcm\u00fcne neden olur ve ciddi yaralanma stresine yan\u0131t verme kapasitelerini bozar. Ya\u015fl\u0131 hastalarda dura kafatas\u0131na s\u0131k\u0131ca yap\u0131\u015f\u0131r ve k\u00f6pr\u00fc olu\u015fturan damarlar gerilir, b\u00f6ylece kafa travmas\u0131ndan kaynaklanan subdural kanama riski artarken, epidural kanama riski azal\u0131r. Ek olarak, 30 ile 70 ya\u015flar\u0131 aras\u0131nda beyin boyutunda yakla\u015f\u0131k %30’luk bir azalma vard\u0131r ve beyin atrofisi, kan\u0131n birikebilece\u011fi alan\u0131 artt\u0131r\u0131r ve subdural kanama ile ili\u015fkili semptom ve bulgular\u0131n geli\u015fimini geciktirebilir. Baz\u0131 ya\u015fl\u0131 eri\u015fkinlerde demans, travmay\u0131 takiben t\u0131bbi de\u011ferlendirmeyi zorla\u015ft\u0131r\u0131r. Serebrovask\u00fcler otoreg\u00fclasyon ya\u015fla birlikte azal\u0131r ve sistemik hipotansiyon d\u00f6nemlerinde beyni potansiyel olarak yaralanmaya daha duyarl\u0131 hale getirir. Ya\u015flanma ile birlikte meydana gelen fizyolojik de\u011fi\u015fiklikler Tablo-1\u2019de \u00f6zetlenmi\u015ftir.<\/p>\n

\u00a0<\/strong>Tablo-1: <\/strong>Yas\u0327lanman\u0131n fizyolojik deg\u0306is\u0327iklikleri ve kafa travmas\u0131 i\u0307c\u0327in klinik o\u0308nemi (3).<\/p>\n

\n\n\n\n\n\n\n\n\n\n\n
Fizyolojik Deg\u0306is\u0327im <\/strong><\/td>\nKafa travmas\u0131 ic\u0327in klinik o\u0308nemi <\/strong><\/td>\n<\/tr>\n
Serebral atrofi <\/strong><\/td>\nAzalan beyin parankimal hacmi araknoid ve dura mater aras\u0131ndaki
\nbos\u0327lug\u0306u art\u0131r\u0131r. Bu, ko\u0308pru\u0308lenen damarlar\u0131n gerilmesine ve y\u0131rt\u0131lmaya kars\u0327\u0131 savunmas\u0131zl\u0131g\u0306a ve dolay\u0131s\u0131yla subdural kanamaya yol ac\u0327ar. Ayr\u0131ca TBH\u2019n\u0131 takiben bilincin bozuklug\u0306unun gecikmis\u0327 prezentasyonuna da neden olabilir, c\u0327u\u0308nku\u0308 beyin parankimine bas\u0131nc\u0327 etkileri uygulamak ic\u0327in daha fazla kan hacmi gereklidir.<\/td>\n<\/tr>\n
Hipertansiyon <\/strong><\/td>\nHipertansiyon, kan damarlar\u0131nda duvar gerginlig\u0306inin artmas\u0131na neden olur. Bu anevrizma olus\u0327umu ve kan damar\u0131 ru\u0308ptu\u0308ru\u0308 ic\u0327in bir risk fakto\u0308ru\u0308du\u0308r ve subaraknoid kanama riskini %180\u2019e kadar art\u0131r\u0131r.<\/td>\n<\/tr>\n
Azalm\u0131s\u0327 serebral otoregu\u0308lasyon <\/strong><\/td>\nSerebral kan ak\u0131s\u0327\u0131n\u0131n bozulmus\u0327 otoregu\u0308lasyonu, kafa travmas\u0131 sonras\u0131 kan ak\u0131s\u0327\u0131nda azalma ve hipoksik beyin hasar\u0131 ile sonuc\u0327lan\u0131r.<\/td>\n<\/tr>\n
Serebrovasku\u0308ler ateroskleroz<\/strong><\/td>\nSerebrovasku\u0308ler otoregu\u0308lasyonun azalmas\u0131na katk\u0131da bulunur. Ateroskleroz, spontan intraserebral kanama riski ile ilis\u0327kilidir.<\/td>\n<\/tr>\n
Artan monoamin oksidaz B konsantrasyonu <\/strong><\/td>\nMonoamin oksidaz B, no\u0308rotransmiterlerin amin giderilmesinden sorumludur. Bu is\u0327lem, serebral hasara neden olan reaktif oksijen tu\u0308rleri (ROS) u\u0308retir. ROS, beynin biyolojik direncini azalt\u0131r ve parankimi yaralanmadan sonra hasara kars\u0327\u0131 savunmas\u0131z b\u0131rak\u0131r.<\/td>\n<\/tr>\n
Yas\u0327lanan mitokondri <\/strong><\/td>\nGecikmis\u0327 elektron tas\u0327\u0131ma zinciri fonksiyonunu ve azalm\u0131s\u0327 adenozin trifosfat u\u0308retimine sebep olur. Bu, beyin hasar\u0131na kars\u0327\u0131 serebral direnci azalt\u0131r.<\/td>\n<\/tr>\n
Azalm\u0131s\u0327 su\u0308peroksit dismutaz (SOD) konsantrasyonlar\u0131 <\/strong><\/td>\nSOD, su\u0308peroksit radikallerinin hidrojen peroksite bo\u0308lu\u0308nmesini katalize etmekten sorumludur. SOD\u2019da azalma, radikallerin birikmesine ve beyin hasar\u0131na kars\u0327\u0131 direncin azalmas\u0131na yol ac\u0327ar.<\/td>\n<\/tr>\n
Artan su\u0308peroksit u\u0308retimi <\/strong><\/td>\nSu\u0308peroksit parankimal hasara ve azalm\u0131s\u0327 yaralanma esneklig\u0306ine yol ac\u0327ar.<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

Etyoloji<\/strong><\/p>\n

Ya\u015fl\u0131 hastalarda d\u00fc\u015fmeler travmatik yaralanmalar\u0131n en s\u0131k etyolojisidir (4). Ara\u015ft\u0131rmalar, 65 ya\u015f\u0131n \u00fczerindeki ki\u015filerde y\u0131lda yakla\u015f\u0131k %27 oran\u0131nda d\u00fc\u015fme riski oldu\u011funu ortaya koymu\u015ftur (5). D\u00fc\u015fmeler i\u00e7in risk fakt\u00f6rleri aras\u0131nda; ileri ya\u015f, fiziksel bozukluklar, \u00f6nceki d\u00fc\u015fme \u00f6yk\u00fcs\u00fc, ila\u00e7 kullan\u0131m\u0131, demans, dengesiz y\u00fcr\u00fcy\u00fc\u015f, g\u00f6rsel-bili\u015fsel ve n\u00f6rolojik bozukluklar yer al\u0131r. Hal\u0131lar, zay\u0131f ayd\u0131nlatma, kaygan veya d\u00fcz olmayan y\u00fczeyler gibi \u00e7evresel fakt\u00f6rler, d\u00fc\u015fme riskinde ek olarak rol oynar. Ya\u015fl\u0131 hastalarda yaralanma mekanizmalar\u0131 genellikle d\u00fc\u015f\u00fck enerjili olan ayn\u0131 zemin seviyesinden d\u00fc\u015fmelerdir ve bu d\u00fc\u015fmeler sonras\u0131 g\u00f6r\u00fclen \u00f6l\u00fcmlerin yar\u0131s\u0131 TBH\u2019na ba\u011fl\u0131 geli\u015fir (6). Bu d\u00fc\u015fmeler gen\u00e7 hastalarda genellikle ciddi yaralanmalara yol a\u00e7mazken, geriatrik pop\u00fclasyonda \u00f6nemli kafa i\u00e7i yaralanmalara yol a\u00e7abilir. Min\u00f6r kafa travmal\u0131 hastalarda ileri ya\u015f\u0131n morbidite ve mortalite i\u00e7in ba\u011f\u0131ms\u0131z bir risk fakt\u00f6r\u00fc oldu\u011fu unutulmamal\u0131d\u0131r (7). D\u00fc\u015fmeler ayn\u0131 zamanda bir semptom olarak g\u00f6r\u00fclmeli ve d\u00fc\u015fmeye neden olabilecek inme, miyokard infarkt\u00fcs\u00fc, gastrointestinal hemoraji, aort diseksiyonu vb. a\u00e7\u0131s\u0131ndan hasta detayl\u0131 bir \u015fekilde de\u011ferlendirilmelidir. Acil servise ba\u015fvuran ileri ya\u015f kafa travmal\u0131 bir hastada hata yapmamak i\u00e7in, d\u00fc\u015f\u00fck enerjili travma mekanizmalar\u0131n\u0131n da ciddi kafa i\u00e7i yaralanmalar\u0131na yol a\u00e7abilece\u011fi ve d\u00fc\u015fmenin alt\u0131nda daha ciddi nedenler olabilece\u011fi ak\u0131lda tutulmal\u0131d\u0131r.<\/p>\n

Motorlu ara\u00e7 kazalar\u0131, ya\u015fl\u0131 hastalarda travmatik yaralanman\u0131n ikinci en yayg\u0131n nedenidir. Bu olgular d\u00fc\u015fmelerden daha az g\u00f6r\u00fclmekle birlikte, motorlu ara\u00e7 \u00e7arp\u0131\u015fmalar\u0131n\u0131n ya\u015fl\u0131 hastalarda \u00f6l\u00fcme neden olma olas\u0131l\u0131\u011f\u0131 gen\u00e7 eri\u015fkinlere g\u00f6redaha y\u00fcksektir (8).<\/p>\n

\u0130lk De\u011ferlendirme<\/strong><\/p>\n

Kafa travmas\u0131 nedeni ile ba\u015fvuran ya\u015fl\u0131 hastalar\u0131n ilk de\u011ferlendirmesi standart travma yakla\u015f\u0131m\u0131ndan farkl\u0131l\u0131k g\u00f6stermez. Birincil de\u011ferlendirmede olas\u0131 hayat\u0131 tehdit edebilecek patolojiler saptanmal\u0131 ve tedavi edilmeli, ikincil de\u011ferlendirmede ise tepeden t\u0131rna\u011fa bir de\u011ferlendirme yap\u0131lmal\u0131d\u0131r. Bununla birlikte ya\u015fl\u0131 hastalara \u00f6zg\u00fc baz\u0131 \u00f6zel durumlar ve zorluklar bulunmaktad\u0131r.<\/p>\n

    \n
  • D\u00fc\u015f\u00fck \u2018Under\u2019<\/em> Triaj Sorunu \u2013 <\/strong>\u00c7oklu g\u00f6zlemsel \u00e7al\u0131\u015fmalar, ya\u015fl\u0131 travma hastalar\u0131nda yetersiz triyaj sorununu ortaya koymaktad\u0131r. 26.565 travma hastas\u0131n\u0131 i\u00e7eren bir retrospektif \u00e7al\u0131\u015fmada, 65 ya\u015f\u0131n \u00fczerindeki hastalarda %49’luk bir d\u00fc\u015f\u00fck triyaj oran\u0131 bildirmi\u015ftir (9). D\u00fc\u015f\u00fck triyaj, ya\u015fl\u0131 eri\u015fkin hastalar\u0131n daha fazla yaralanma riski alt\u0131nda oldu\u011funun kabul edilmemesinden ve geleneksel triyaj ara\u00e7lar\u0131na ya\u015fl\u0131 hastalarda yaralanma belirtilerine kar\u015f\u0131 nispeten duyars\u0131z olmas\u0131ndan kaynaklanmaktad\u0131r. Benzer \u015fekilde geriatrik hastalarda Glasgow Koma Skalas\u0131 (GKS) daha az yol g\u00f6stericidir. Bu pop\u00fclasyondaki fizyolojik de\u011fi\u015fiklikler g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda, normal veya nispeten y\u00fcksek bir GKS skoru olsa bile \u00f6nemli intrakranial hasar mevcut olabilir (10). Geriatrik travma hastalar\u0131 ile ilgili triyaj kararlar\u0131na rehberlik edecek s\u0131n\u0131rl\u0131 prospektif veri olmas\u0131na ra\u011fmen, bu pop\u00fclasyonda ciddi yaralanma ve \u00f6l\u00fcm riskinin artmas\u0131 g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda, travma mekanizmas\u0131ndan ba\u011f\u0131ms\u0131z olarak 70 ya\u015f \u00fcst\u00fc travma hastalar\u0131n\u0131n m\u00fcmk\u00fcn oldu\u011funda travma ekibi aktivasyonu ile bir travma merkezinde de\u011ferlendirilmesi \u00f6nerilmektedir (11). Geleneksel skorlama sitemlerinin yetersiz olmas\u0131 nedeni ile ileri ya\u015f kafa travmas\u0131 olan hastalarda komorbidite yaratan durumlar\u0131n ve k\u0131r\u0131lganl\u0131\u011f\u0131n b\u00fct\u00fcnc\u00fcl olarak de\u011ferlendirilmesi daha do\u011fru bir yakla\u015f\u0131m olacakt\u0131r. K\u0131r\u0131lganl\u0131k, \u00e7oklu organ sistemlerinde fizyolojik strese dayanma yetene\u011finin bozulmas\u0131na yol a\u00e7an azalm\u0131\u015f bir fizyolojik rezerv anlam\u0131na gelir. Ya\u015fl\u0131 kafa travmas\u0131 olan hastalarda k\u0131r\u0131lganl\u0131k, 15 de\u011fi\u015fkenli Travmaya \u00d6zg\u00fc K\u0131r\u0131lganl\u0131k \u0130ndeksi kullan\u0131larak de\u011ferlendirilebilir ve geriatrik travma hastalar\u0131 i\u00e7in en uygun hastane ve tedavinin belirlenmesine yard\u0131mc\u0131 olabilir (12). Bu \u00f6neriler, geriatrik travma hastalar\u0131n\u0131n y\u00f6netiminde \u00f6nemli bir sorun olan yetersiz triyaj konusunda klinisyenlere yard\u0131mc\u0131 olacakt\u0131r.<\/li>\n
  • \u00d6yk\u00fc \u2013<\/strong> Baz\u0131 ya\u015fl\u0131 travma hastalar\u0131nda zor olsa da, m\u00fcmk\u00fcn oldu\u011funda detayl\u0131 bir \u00f6yk\u00fc almak olduk\u00e7a \u00f6nemlidir. Travman\u0131n olu\u015f \u015fekli ve mekanizma hakk\u0131nda standart sorgulamalara ek olarak, ya\u015fl\u0131 hastalara (veya aile \u00fcyelerine, 112 ekibine veya bilgi sahibi olabilecek di\u011fer ki\u015filere) sorulacak \u00f6nemli sorular \u015funlard\u0131r:\n
      \n
    • Travmadan hemen \u00f6nce ne oldu? (bilin\u00e7 de\u011fi\u015fikli\u011fi, nefes almada zorluk, g\u00f6rme bozuklu\u011fu vb)<\/li>\n
    • Hasta hangi ila\u00e7lar\u0131 al\u0131yor? (antikoag\u00fclan, antitrombosit, beta bloker, kalsiyum kanal blokeri vb)<\/li>\n
    • Hastan\u0131n altta yatan hastal\u0131klar\u0131 nelerdir? (kardiyovask\u00fcler hastal\u0131k, b\u00f6brek hastal\u0131\u011f\u0131, diyabet vb)<\/li>\n
    • Travmatik olaydan \u00f6nce hastan\u0131n ba\u015flang\u0131\u00e7taki motor ve bili\u015fsel i\u015flev d\u00fczeyi nas\u0131ld\u0131?<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

      \u00d6zellikle hastan\u0131n bilinen hastal\u0131klar\u0131 ve kulland\u0131\u011f\u0131 ila\u00e7lar detayl\u0131 olarak sorgulanmal\u0131d\u0131r. Bazen hasta ve yak\u0131nlar\u0131 hastan\u0131n kulland\u0131\u011f\u0131 ila\u00e7lar\u0131 hat\u0131rlamayabilir. Bu durumda e-nab\u0131z sistemi \u00fczerinden hastan\u0131n kulland\u0131\u011f\u0131 ila\u00e7lar sorgulanmal\u0131d\u0131r.<\/p>\n

      G\u00f6r\u00fcnt\u00fcleme<\/strong><\/p>\n

      Geriatrik hastalardaki hemen hemen t\u00fcm kafa travmas\u0131 olgular\u0131nda, bilgisayarl\u0131 beyin tomografi (BT) taramas\u0131n\u0131n yap\u0131lmas\u0131 gerekmektedir. Bu pop\u00fclasyonda artan yaralanma riskine ek olarak, n\u00f6rolojik muayene \u00f6nemli kafa i\u00e7i kanama belirtilerini saptamak i\u00e7in g\u00fcvenilir olmayabilir (13). G\u00f6zlemsel \u00e7al\u0131\u015fmalar, min\u00f6r bir yaralanma mekanizmas\u0131 olan ve n\u00f6rolojik muayenede anormallik olmayan hastalarda hala \u00f6nemli subdural veya epidural kanama olabilece\u011fini vurgulamaktad\u0131r (11).<\/p>\n

      Hafif kafa travmas\u0131 olan yeti\u015fkinler i\u00e7in \u00e7e\u015fitli klinik tahmin kurallar\u0131 mevcuttur. Bunlar\u0131n aras\u0131nda en pop\u00fcler olanlar\u0131 New Orleans Kriterleri, Kanada Beyin BT Kurallar\u0131, ve NEXUS II kriterleridir (14). New Orleans Kriterleri\u2019ne g\u00f6re, ya\u015f > 60 olmas\u0131 BT’de akut travmatik intrakraniyal lezyonlar i\u00e7in bir risk fakt\u00f6r\u00fcd\u00fcr; bu nedenle kafa travmal\u0131 ya\u015fl\u0131 hastalarda BT \u00f6nerilir. Kanada Beyin BT Kurallar\u0131\u2019na g\u00f6re \u2265 65 ya\u015f, 7 g\u00fcn i\u00e7inde \u00f6l\u00fcm ve beyin cerrahisi m\u00fcdahalesi i\u00e7in bir risk fakt\u00f6r\u00fcd\u00fcr; bu nedenle kafa travmas\u0131 olan ya\u015fl\u0131 eri\u015fkin hastalarda BT \u00f6nerilir. NEXUS II kriterlerine g\u00f6re, min\u00f6r kafa travmas\u0131 olan bir hasta \u2265 65 ya\u015f\u0131ndaysa kafa i\u00e7i yaralanma olas\u0131l\u0131\u011f\u0131 g\u00fcvenli bir \u015fekilde d\u0131\u015flanamaz. ACEP\u2019in yay\u0131nlad\u0131\u011f\u0131 klinik politikas\u0131nda, bilin\u00e7 kayb\u0131 veya amnezisi olan min\u00f6r kafa travmal\u0131 \u2265 60 ya\u015f hastalarda (A d\u00fczeyi \u00f6neri) ve bilin\u00e7 kayb\u0131 veya amnezi olmasa bile min\u00f6r kafa travmas\u0131 olan \u2265 65 ya\u015f hastalara (B d\u00fczeyi \u00f6neri) BT \u00f6nerilmektedir (15).<\/p>\n

      Antikoag\u00fclan Kullanan Hastalar<\/strong><\/p>\n

      Kafa travmas\u0131 ile ba\u015fvuran ya\u015fl\u0131 hastalar\u0131n yakla\u015f\u0131k %10’u varfarin kullan\u0131rken, \u00f6nemli bir y\u00fczdesi di\u011fer antikoag\u00fclanlar\u0131 veya antitrombositer ajanlar\u0131 kullanmaktad\u0131r (16). Varfarin kullanan asemptomatik kafa travmal\u0131 hastalarda kafa i\u00e7i kanama oran\u0131 baz\u0131 \u00e7al\u0131\u015fmalarda %15’e kadar \u00e7\u0131kmaktad\u0131r (17). Retrospektif verilere g\u00f6re, terap\u00f6tik antikoag\u00fclasyon bile kafa travmal\u0131 geriatrik hastada olumsuz sonu\u00e7larla ili\u015fkilidir (18). Kanaman\u0131n h\u0131z\u0131 ve hacmi, intrakranial kanamadan kaynaklanan morbidite ve mortalitenin en \u00f6nemli belirleyicileri aras\u0131nda oldu\u011fundan, ihtiya\u00e7 halinde antikoag\u00fclasyonun tersine \u00e7evrilmesi gerekmektedir (19).<\/p>\n

      BT’de travma sonras\u0131 intrakranial kanama saptanan ve varfarin alan t\u00fcm ya\u015fl\u0131 hastalarda, ba\u015fvuru sonras\u0131 ilk 2 saat i\u00e7erisinde INR de\u011feri <1.6 olarak d\u00fczeltilmelidir (20). Ayn\u0131 yakla\u015f\u0131m, varfarin alan ve mental durumda herhangi bir d\u00fc\u015f\u00fc\u015f g\u00f6steren veya n\u00f6rolojik defisit geli\u015ftiren ya da supraterap\u00f6tik INR d\u00fczeyi saptanan ve herhangi bir \u015fekilde s\u00fcrekli kafa travmas\u0131 olan daha ya\u015fl\u0131 travma hastalar\u0131nda da \u00f6nerilmektedir (21). Antikoag\u00fclasyonu tersine \u00e7evirmek i\u00e7in taze donmu\u015f plazma (TDP), K vitamini, kriyopresipitat, protrombin \u00e7\u00f6kelti kompleksi (PCC) ve rekombinant insan fakt\u00f6r\u00fc VIIa dahil olmak \u00fczere \u00e7e\u015fitli tedaviler kullan\u0131labilir. TDP, a\u015f\u0131r\u0131 s\u0131v\u0131 y\u00fcklenmesi riskini en aza indirmek i\u00e7in m\u00fcmk\u00fcn olan en k\u00fc\u00e7\u00fck hacimler kullan\u0131larak uygulanmal\u0131d\u0131r. Potansiyel olarak ya\u015fam\u0131 tehdit eden kanaman\u0131n ba\u015flang\u0131\u00e7 tedavisi i\u00e7in, varfarinin kesilmesi, TDP transf\u00fczyonunu (ba\u015flang\u0131\u00e7 dozu 2-3 \u00fcnite) ve yava\u015f intraven\u00f6z inf\u00fczyonla (20 dk\u2019dan uzun) 10 mg K vitamini uygulanmas\u0131 \u00f6nerilmektedir (11). Ya\u015fam\u0131 tehdit eden kanamalarda e\u011fer ula\u015f\u0131labiliniyorsa TDP yerine PCC veya fakt\u00f6r VIIa verilebilir. Tablo-2\u2019de ya\u015fam\u0131 tehdit eden kanamas\u0131 olan hastalarda varfarine ba\u011fl\u0131 antikoag\u00fclasyonu tersine \u00e7evirmek i\u00e7in ilk acil tedavi \u00f6zetlemektedir.<\/p>\n

      Tablo-2:<\/strong> Eri\u015fkinlerde ya\u015fam\u0131 tehdit eden kanama i\u00e7in varfarinden antikoag\u00fclasyonun acil\u00a0<\/span>olarak tersine \u00e7evrilmesi (11).<\/span><\/p>\n

      \n\n\n\n\n\n\n\n\n\n\n\n
      4 fakt\u00f6rl\u00fc protrombin kompleks konsantresi (4F PCC) mevcutsa (tercih edilen yakla\u015f\u0131m)<\/strong><\/td>\n<\/tr>\n
      1. 4F PCC 1500-2000 \u00fcnite IV 10 dk boyunca verin. \u0130nf\u00fczyon tamamland\u0131ktan 15 dk sonra INR’yi kontrol edin. INR \u22641.5 de\u011filse, ek 4F PCC verin.<\/td>\n<\/tr>\n
      2. 10 ila 20 dk\u2019da K vitamini 10 mg IV verin.<\/td>\n<\/tr>\n
      3 fakt\u00f6rl\u00fc protrombin kompleks konsantresi (3F PCC) mevcutsa <\/strong><\/td>\n<\/tr>\n
      1. 3F PCC 1500-2000 \u00fcnite IV 10 dk boyunca verin. \u0130nf\u00fczyon tamamland\u0131ktan 15 dk sonra INR’yi kontrol edin. INR \u22641.5 de\u011filse, ek 3F PCC verin.<\/td>\n<\/tr>\n
      2. Fakt\u00f6r VIIa 20 mcg\/kg IV verin veya 2 \u00fcnite TDP IV h\u0131zl\u0131 inf\u00fczyonla verin. A\u015f\u0131r\u0131 hacim y\u00fcklenmesi endi\u015fesi varsa Fakt\u00f6r VIIa tercih edilebilir.<\/td>\n<\/tr>\n
      3. 10 ila 20 dk\u2019da 10 mg K vitamini IV verin.<\/td>\n<\/tr>\n
      3F PCC <\/strong>ve<\/strong> 4F PCC mevcut de\u011filse<\/strong><\/td>\n<\/tr>\n
      1. H\u0131zl\u0131 inf\u00fczyonla TDP 2 \u00fcnite IV verin. \u0130nf\u00fczyon tamamland\u0131ktan 15 dk sonra INR’yi kontrol edin. INR \u22651.5 ise, 2 ek \u00fcnite TDP IV h\u0131zl\u0131 inf\u00fczyon uygulay\u0131n. INR \u22641.5 olana kadar i\u015flemi tekrarlay\u0131n. A\u015f\u0131r\u0131 hacim y\u00fcklenmesi endi\u015fesi varsa TDP inf\u00fczyonlar\u0131 aras\u0131nda loop di\u00fcreti\u011fi uygulanabilir.<\/td>\n<\/tr>\n
      2. 10 ila 20 dk\u2019da K vitamini 10 mg IV verin.<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

      Baz\u0131 ya\u015fl\u0131 travma hastalar\u0131 varfarin d\u0131\u015f\u0131nda antikoag\u00fclan kullan\u0131yor olabilir. Direkt oral antikoag\u00fclan (\u00d6r; dabigatran) kullanan ve hayat\u0131 tehdit eden kafa i\u00e7i kanamas\u0131 olan hastalarda antikoag\u00fclasyonu tersine \u00e7evirmek i\u00e7in gerekli acil yakla\u015f\u0131mlar Tablo-3\u2019de \u00f6zetlenmi\u015ftir.<\/p>\n

      Tablo-3:<\/strong> Direkt oral antikoag\u00fclanlarla ili\u015fkili kanamalar\u0131 tersine \u00e7evirme stratejileri (11).<\/p>\n

      \n\n\n\n
      \n
        \n
      • Dabigatran (Pradaxa)<\/li>\n<\/ul>\n<\/td>\n
      		\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Idarucizumab<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Aktif PCC (\u00d6r; FEIBA)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Antifibrinolitik ajan (\u00d6r; traneksamik asit)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Antikoag\u00fclan\u0131n kesilmesi<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Aktif k\u00f6m\u00fcr (son doz 2 saat i\u00e7inde ise)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Hemodiyaliz<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Anemi i\u00e7in gerekirse RBC transf\u00fczyonlar\u0131<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Trombositopeni veya bozulmu\u015f trombosit fonksiyonu i\u00e7in gerekirse trombosit transf\u00fczyonlar\u0131 (\u00d6r; aspirin nedeniyle)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0 Uygunsa cerrahi\/endoskopik m\u00fcdahale<\/td>\n<\/tr>\n

      \n
        \n
      • Rivaroksaban (Xarelto)<\/li>\n
      • Apiksaban (Eliquis)<\/li>\n
      • Edoksaban (Lixiana)<\/li>\n<\/ul>\n

         <\/td>\n

      		\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Andeksanat alfa (AndexXa) veya 4 fakt\u00f6rl\u00fc etkinle\u015ftirilmemi\u015f bir PCC (\u00d6r; Kcentra)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Antifibrinolitik ajan (\u00d6r; traneksamik asit)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Antikoag\u00fclan\u0131n kesilmesi<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Aktif k\u00f6m\u00fcr (son doz yeterince yeniyse)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Anemi i\u00e7in gerekirse RBC transf\u00fczyonlar\u0131<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Trombositopeni veya bozulmu\u015f trombosit fonksiyonu i\u00e7in gerekirse trombosit transf\u00fczyonlar\u0131 (\u00d6r; aspirin nedeniyle)<\/p>\n

      \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0 Uygunsa cerrahi\/endoskopik m\u00fcdahale<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

      Antikoag\u00fclan kullanan ve ilk g\u00f6r\u00fcnt\u00fclemede kanama saptanmayan hastalarda ilerleyen d\u00f6nemlerde gecikmi\u015f kanamalar g\u00f6r\u00fclebilir. Mevcut s\u0131n\u0131rl\u0131 kan\u0131tlar nedeniyle, varfarin tedavisi g\u00f6ren ve kafa travmas\u0131 ge\u00e7iren ancak ilk BT taramas\u0131nda akut intrakranial kanama saptanmayan hastalar i\u00e7in uygun g\u00f6zlemin nas\u0131l olmas\u0131 gerekti\u011fi konusunda tart\u0131\u015fmalar devam etmektedir. Bu t\u00fcr hastalar i\u00e7in her 2 saatte bir yeniden de\u011ferlendirme (odaklanm\u0131\u015f, standart bir n\u00f6rolojik muayene dahil) ile 12 saatlik bir g\u00f6zlem periyodu \u00f6nerilmektedir (11). Bu s\u00fcre i\u00e7inde n\u00f6rolojik muayenesinde herhangi bir de\u011fi\u015fiklik olmayan ve klinik olarak stabil kalan hastalar taburcu edilebilir. Taburculuk s\u0131ras\u0131nda mutlaka hasta ve yak\u0131nlar\u0131 bilgilendirilmeli, acil durumlar anlat\u0131larak gereklilik halinde h\u0131zl\u0131ca acil servise ba\u015fvurmalar\u0131 \u00f6nerilmelidir.<\/p>\n

      Sonu\u00e7<\/strong><\/p>\n

      Kafa travmas\u0131 olan ya\u015fl\u0131 hastalar\u0131n acil servis y\u00f6netimi zorlay\u0131c\u0131 olabilmektedir. E\u015flik eden ek hastal\u0131klar, travmaya ba\u011fl\u0131 geli\u015febilecek patolojileri olumsuz etkileyecek ila\u00e7 kullan\u0131m\u0131 ve standart travma yakla\u015f\u0131mlar\u0131n\u0131n yetersiz kalmas\u0131 gibi unsurlar bu zorlu\u011fu yaratan etmenler aras\u0131ndad\u0131r. Bu hasta gurubunda hata riskini en aza indirebilmek i\u00e7im hem ya\u015fl\u0131l\u0131\u011fa ba\u011fl\u0131 geli\u015fen farkl\u0131l\u0131klar\u0131n hem de ki\u015fi \u00f6zelinde mevcut olan risk fakt\u00f6rlerinin iyi bilinmesi ve sorgulanmas\u0131 gerekmektedir.<\/p>\n

      Kaynaklar<\/strong><\/p>\n

        \n
      1. Geriatric Head Injury – PubMed [Internet]. [cited 2022 Jul 18]. Available from: https:\/\/pubmed.ncbi.nlm.nih.gov\/31971741\/.<\/li>\n
      2. Filer W, Harris M. Falls and traumatic brain injury among older adults. N C Med J. 2015 Apr;76(2):111\u20134.<\/li>\n
      3. Beedham W, Peck G, Richardson SE, Tsang K, Fertleman M, Shipway DJ. Head injury in the elderly – an overview for the physician. Clin Med Lond Engl. 2019 Mar;19(2):177\u201384.<\/li>\n
      4. Labib N, Nouh T, Winocour S, Deckelbaum D, Banici L, Fata P, et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma. 2011 Dec;71(6):1908\u201314.<\/li>\n
      5. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA. 2007 Jan 3;297(1):77\u201386.<\/li>\n
      6. Galvagno SM, Nahmias JT, Young DA. Advanced trauma life support\u00ae Update 2019: management and applications for adults and special populations. Anesthesiol Clin. 2019;37(1):13\u201332.<\/li>\n
      7. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc. 2006 Oct;54(10):1590\u20135.<\/li>\n
      8. Keller JM, Sciadini MF, Sinclair E, O\u2019Toole RV. Geriatric trauma:demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-165.<\/li>\n
      9. Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg Chic Ill 1960. 2008 Aug;143(8):776\u201381; discussion 782.<\/li>\n
      10. Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J. 2015;32(8):613\u20135.<\/li>\n
      11. Colwell C, Moreira M, Grayzel J. Geriatric trauma: Initial evaluation and management. UpToDate Walth MA UpToDate. 2021.<\/li>\n
      12. Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Tang A, O\u2019Keeffe T, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg. 2014 Jul;219(1):10-17.e1.<\/li>\n
      13. Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, et al. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med Off J Soc Acad Emerg Med. 2006 Mar;13(3):302\u20137.<\/li>\n
      14. Mori K, Abe T, Matsumoto J, Takahashi K, Takeuchi I. Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department. Acad Emerg Med Off J Soc Acad Emerg Med. 2021 Apr;28(4):435\u201343.<\/li>\n
      15. Jagoda AS, Bazarian JJ, Bruns JJ, Cantrill SV, Gean AD, Howard PK, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. J Emerg Nurs. 2009 Apr;35(2):e5-40.<\/li>\n
      16. Kirsch MJ, Vrabec GA, Marley RA, Salvator AE, Muakkassa FF. Preinjury warfarin and geriatric orthopedic trauma patients: a case-matched study. J Trauma. 2004 Dec;57(6):1230\u20133.<\/li>\n
      17. Li J, Brown J, Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet Lond Engl. 2001 Mar 10;357(9258):771\u20132.<\/li>\n
      18. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma. 2007 Sep;63(3):525\u201330.<\/li>\n
      19. Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, et al. Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke. 2006 Jan;37(1):151\u20135.<\/li>\n
      20. Calland JF, Ingraham AM, Martin N, Marshall GT, Schulman CI, Stapleton T, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S345-350.<\/li>\n
      21. Ivascu FA, Janczyk RJ, Junn FS, Bair HA, Bendick PJ, Howells GA. Treatment of trauma patients with intracranial hemorrhage on preinjury warfarin. J Trauma. 2006 Aug;61(2):318\u201321.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

        Kafa travmas\u0131, ya\u015fl\u0131 hastalar aras\u0131nda \u00f6nde gelen morbidite ve mortalite nedenidir. Travmatik yaralanmalar sonras\u0131 ciddi yaralanma riskini art\u0131ran \u00e7ok say\u0131da kronik t\u0131bbi…<\/p>\n","protected":false},"author":1185,"featured_media":434,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10026,10025,10024],"class_list":["post-433","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-acil-servis","tag-geriatrik-travma","tag-kafa-travmasi"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/433","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=433"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/433\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/434"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=433"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=433"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=433"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}