{"id":645,"date":"2023-03-09T21:07:31","date_gmt":"2023-03-09T18:07:31","guid":{"rendered":"https:\/\/tatd.org.tr\/travma\/?p=645"},"modified":"2023-03-11T16:15:06","modified_gmt":"2023-03-11T13:15:06","slug":"travmatik-yaralanmayi-takiben-major-kanama-ve-koagulopati-yonetimi-avrupa-kilavuzu-altinci-edisyon","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/travma\/genel\/travmatik-yaralanmayi-takiben-major-kanama-ve-koagulopati-yonetimi-avrupa-kilavuzu-altinci-edisyon\/","title":{"rendered":"Travmatik Yaralanmay\u0131 Takiben Maj\u00f6r Kanama ve Koag\u00fclopati Y\u00f6netimi Avrupa K\u0131lavuzu &#8211; Alt\u0131nc\u0131 edisyon"},"content":{"rendered":"\n<p>Travma sonras\u0131 kanama ve buna ba\u011fl\u0131 travmatik koag\u00fclopati, uygun ve zaman\u0131nda tan\u0131n\u0131p m\u00fcdahale edilmedi\u011fi takdirde, potansiyel olarak \u00f6nlenebilir \u00f6l\u00fcm\u00fcn \u00f6nde gelen nedenleri olmaya devam etmekte.&nbsp;<\/p>\n\n\n\n<p>Kanamal\u0131 travma hastas\u0131n\u0131n bak\u0131m\u0131 ve y\u00f6netiminin optimize edilebilmesi amac\u0131yla, tedavilerimize k\u0131lavuzlar e\u015fli\u011finde y\u00f6n vermekteyiz.&nbsp;<\/p>\n\n\n\n<p>Be\u015finci edisyonu 2019 y\u0131l\u0131nda yay\u0131nlanan, \u201cThe European guideline on&nbsp;management of&nbsp;major bleeding and&nbsp;coagulopathy following&nbsp;trauma\u201d alt\u0131nc\u0131 edisyonu, ge\u00e7ti\u011fimiz hafta yay\u0131nland\u0131 (1).&nbsp;<\/p>\n\n\n\n<p>Yeni k\u0131lavuzda min\u00f6r de\u011fi\u015fikliklerin ve kan\u0131t d\u00fczeyi de\u011fi\u015fikliklerinin yan\u0131 s\u0131ra, en g\u00f6ze \u00e7arpan de\u011fi\u015fiklikler, hastane \u00f6ncesi FAST \u00f6nerisi, hastane \u00f6ncesi pelvik bandaj \u00f6nerisi, fakt\u00f6r Xa inhibit\u00f6r\u00fc kullananlarda andexanet alfa \u00f6nerisi, antiplatelet ajan kullanan hastalarda de\u011fi\u015fen trombosit \u00f6nerisi i\u00e7in yap\u0131lm\u0131\u015f gibi g\u00f6z\u00fckmekte.&nbsp;<\/p>\n\n\n\n<p>\u0130yi okumalar.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Travmatik Yaralanmay\u0131 Takiben Maj\u00f6r Kanama ve Koag\u00fclopati Y\u00f6netimi Avrupa K\u0131lavuzu Alt\u0131nc\u0131 Edisyon \u00d6nerileri<\/h3>\n\n\n\n<figure class=\"wp-block-image size-large\"><img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"508\" src=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6-1024x508.png\" alt=\"\" class=\"wp-image-646\" srcset=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6-1024x508.png 1024w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6-300x149.png 300w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6-768x381.png 768w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6-1200x596.png 1200w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2023\/03\/d8a1cf893b4759567307372b364afba6.png 1338w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<h4 class=\"wp-block-heading\">1. Ba\u015flang\u0131\u00e7 res\u00fcsitasyonu ve daha fazla kanaman\u0131n \u00f6nlenmesi&nbsp;<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Minimal uzam\u0131\u015f s\u00fcre<\/h5>\n\n\n\n<p><strong>\u00d6neri 1 <\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Ciddi \u015fekilde yaralanm\u0131\u015f hastalar\u0131n do\u011frudan uygun bir travma merkezine nakledilmesi \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Yaralanma ile kanama kontrol\u00fc aras\u0131nda ge\u00e7en s\u00fcrenin en aza indirilmesi \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Lokal kanama kontrol\u00fc<\/h5>\n\n\n\n<p><strong>\u00d6neri 2<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hayat\u0131 tehdit eden kanaman\u0131n s\u0131n\u0131rland\u0131r\u0131lmas\u0131 i\u00e7in a\u00e7\u0131k yaralara lokal kompresyon \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Ameliyat \u00f6ncesinde a\u00e7\u0131k ekstremite yaralanmalar\u0131ndan kaynaklanan hayat\u0131 tehdit eden kanamay\u0131 durdurmak i\u00e7in ek turnike kullan\u0131m\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Ventilasyon<\/h5>\n\n\n\n<p><strong>\u00d6neri 3<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Havayolu obstr\u00fcksiyonu, bilin\u00e7 de\u011fi\u015fikli\u011fi [Glasgow Koma Skalas\u0131 (GCS)\u22648], hipoventilasyon veya hipoksemi varl\u0131\u011f\u0131nda endotrakeal ent\u00fcbasyonun veya alternatif hava yolu y\u00f6netiminin gecikmeden yap\u0131lmas\u0131 \u00f6neriliyor (1B). <em><strong>(Yeni \u00f6neri)<\/strong><\/em><\/li>\n\n\n\n<li>Hipoksemiden ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (1A).<\/li>\n\n\n\n<li>A\u015f\u0131r\u0131 kan kayb\u0131 tehditi varl\u0131\u011f\u0131 hari\u00e7, hiperoksemiden ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (2B).<\/li>\n\n\n\n<li>Travma hastalar\u0131na normoventilasyon \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Serebral herniasyon belirtileri varl\u0131\u011f\u0131nda hayat kurtar\u0131c\u0131 bir \u00f6nlem olarak hiperventilasyon \u00f6neriliyor (2C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Hastane \u00f6ncesi kan \u00fcr\u00fcn\u00fc kullan\u0131m\u0131<\/h5>\n\n\n\n<p><strong>\u00d6neri 4<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>An itibariyle hastane \u00f6ncesi kan \u00fcr\u00fcnlerinin kullan\u0131m\u0131 lehine veya aleyhine net bir \u00f6neri veya tavsiyede bulunulmamaktad\u0131r <em><strong>(Yeni \u00f6neri)<\/strong><\/em>. <\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">2. Kanama tan\u0131s\u0131 ve takibi<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">\u0130lk de\u011ferlendirme<\/h5>\n\n\n\n<p><strong>\u00d6neri 5<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hekimin, hasta fizyolojisi, anatomik yaralanma paterni, yaralanma mekanizmas\u0131 ve ilk res\u00fcsitasyona hastan\u0131n yan\u0131t\u0131n\u0131n bir kombinasyonunu kullanarak travmatik kanaman\u0131n boyutunu klinik olarak de\u011ferlendirmesi \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Hipovolemik \u015fokun derecesini ve transf\u00fczyon gerekliliklerini de\u011ferlendirmek i\u00e7in \u015fok indeksinin (\u015e\u0130) ve\/veya nab\u0131z bas\u0131nc\u0131n\u0131n kullan\u0131lmas\u0131 \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Acil m\u00fcdahale<\/h5>\n\n\n\n<p><strong>\u00d6neri 6<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanama kayna\u011f\u0131 bariz olan, ve \u015fiddetli hemorajik \u015fok ile ba\u015fvuran ve kanama kayna\u011f\u0131 \u00f6ng\u00f6r\u00fclen hastalara acil bir kanama kontrol prosed\u00fcr\u00fc uygulanmas\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">\u0130leri tetkik<\/h5>\n\n\n\n<p><strong>\u00d6neri 7<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanama kayna\u011f\u0131 tan\u0131mlanamam\u0131\u015f, ancak acil kanama kontrol\u00fcne ihtiya\u00e7 duymayan hastalar\u0131n, kanama kayna\u011f\u0131n\u0131 belirlemek i\u00e7in h\u0131zl\u0131ca ileri tetkik yapmas\u0131 \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">G\u00f6r\u00fcnt\u00fcleme<\/h5>\n\n\n\n<p><strong>\u00d6neri 8<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Torakoabdominal yaralanmal\u0131 hastalarda hemo-\/pn\u00f6motoraks, hemoperikardiyum ve\/veya serbest abdominal s\u0131v\u0131n\u0131n saptanmas\u0131 i\u00e7in, e\u011fer nakli geciktirmeden yap\u0131lmas\u0131 m\u00fcmk\u00fcnse, hastane \u00f6ncesi ultrasonografinin (PHUS) kullan\u0131lmas\u0131 \u00f6neriliyor (2B). <em><strong>(Yeni \u00f6neri)<\/strong><\/em><\/li>\n\n\n\n<li>Torakoabdominal yaralanmas\u0131 olan hastalarda FAST yatak ba\u015f\u0131 ultrasonografinin (POCUS) kullan\u0131lmas\u0131 \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Yaralanma tipinin ve olas\u0131 kanama kayna\u011f\u0131n\u0131n saptanmas\u0131 ve tan\u0131mlanmas\u0131 i\u00e7in kontrastl\u0131 t\u00fcm v\u00fccut BT kullan\u0131larak erken g\u00f6r\u00fcnt\u00fcleme yap\u0131lmas\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<p><em>REACT-2 \u00e7al\u0131\u015fma ikincil analizlerine g\u00f6re, ciddi yaralanma i\u00e7in y\u00fcksek pozitif prediktif de\u011feri olan, acil t\u00fcm v\u00fccut BT i\u00e7in revize edilmi\u015f 10 klinik kriter seti Tablo 1&#8217;de g\u00f6sterilmi\u015ftir<\/em>(2).<\/p>\n\n\n\n<figure class=\"wp-block-table\"><div class=\"pcrstb-wrap\"><table><tbody><tr><td><strong>T\u00fcm v\u00fccut BT i\u00e7in y\u00fcksek pozitif prediktif de\u011fere sahip revize kriterler (REACT-2 \u00e7al\u0131\u015fmas\u0131)<\/strong>(2)<\/td><\/tr><tr><td>Hastaneye geli\u015finde a\u015fa\u011f\u0131daki parametrelerden birine sahip travma hastalar\u0131<\/td><\/tr><tr><td>Sistolik kan bas\u0131nc\u0131 &lt; 100 mmHg<\/td><\/tr><tr><td>Tahmini eksternal kan kayb\u0131 \u2265\u2009500 ml<\/td><\/tr><tr><td>GKS Skoru \u2264\u2009 13 veya anormal pupil reaksiyonu<\/td><\/tr><tr><td><em>VE\/VEYA<\/em><\/td><\/tr><tr><td>A\u015fa\u011f\u0131daki tan\u0131lardan birine ait klinik \u015f\u00fcphe olan hastalar:<\/td><\/tr><tr><td>En az iki uzun kemikte k\u0131r\u0131k<\/td><\/tr><tr><td>Yelken g\u00f6\u011f\u00fcs, g\u00f6\u011f\u00fcste a\u00e7\u0131k yara, \u00e7oklu kot k\u0131r\u0131klar\u0131<\/td><\/tr><tr><td>Ciddi abdominal yaralanma<\/td><\/tr><tr><td>Pelvik frakt\u00fcr<\/td><\/tr><tr><td>Anstabil vertebra frakt\u00fcr\u00fc\/spinal kord bas\u0131s\u0131<\/td><\/tr><tr><td><em>VE\/VEYA<\/em><\/td><\/tr><tr><td>A\u015fa\u011f\u0131daki yaralanma mekanizmalar\u0131ndan birine sahip hastalar:<\/td><\/tr><tr><td>Y\u00fcksekten d\u00fc\u015fme (&gt;4 m)<\/td><\/tr><tr><td>G\u00f6\u011f\u00fcs\/abdomende s\u0131k\u0131\u015fma<\/td><\/tr><\/tbody><\/table><\/div><figcaption class=\"wp-element-caption\">Tablo1. REACT-2 verilerinin ikincil analizine dayanan ciddi yaralanma i\u00e7in y\u00fcksek pozitif prediktif de\u011feri olan acil t\u00fcm v\u00fccut BT i\u00e7in revize edilmi\u015f 10 klinik kriter seti. Hasta alt gruplar\u0131yla yap\u0131lan posthoc analizlere g\u00f6re, bu kriterler t\u00fcm hastalar i\u00e7in ge\u00e7erli olmayabilir ve hedefe y\u00f6nelik bir yakla\u015f\u0131m gerekebilir.<\/figcaption><\/figure>\n\n\n\n<h5 class=\"wp-block-heading\">Hemoglobin<\/h5>\n\n\n\n<p><strong>\u00d6neri 9<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Normal aral\u0131ktaki bir ba\u015flang\u0131\u00e7 de\u011feri erken evre kanamay\u0131 maskeleyebilece\u011finden, kanama i\u00e7in bir laboratuvar belirteci olarak tekrarlanan Hb ve\/veya hct \u00f6l\u00e7\u00fcmlerinin kullan\u0131lmas\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Kan laktat ve baz defisiti<\/h5>\n\n\n\n<p><strong>\u00d6neri 10<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanama ve doku hipoperf\u00fczyonunun derecesini tahmin etmek ve izlemek i\u00e7in kan laktat\u0131 hassas bir test olarak \u00f6neriliyor; laktat \u00f6l\u00e7\u00fcm imkan\u0131 yoksa, baz eksikli\u011fi uygun bir alternatif olabilir (1B). <em><strong>(Laktat \u00f6nceliklendirilmi\u015f)<\/strong><\/em><\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Koag\u00fclasyon takibi<\/h5>\n\n\n\n<p><strong>\u00d6neri 11<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Protrombin zaman\u0131 (PT)\/uluslararas\u0131 normalle\u015ftirilmi\u015f oran (INR), Clauss fibrinojen d\u00fczeyi ve trombosit say\u0131s\u0131 ve\/veya yatakba\u015f\u0131 PT\/INR ve\/veya viskoelastik y\u00f6ntem gibi geleneksel bir laboratuvar y\u00f6ntemi kullan\u0131larak hemostaz\u0131n erken ve tekrar tekrar izlenmesi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Trombosit fonksiyon takibi<\/h5>\n\n\n\n<p><strong>\u00d6neri 12<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Trombosit fonksiyon bozuklu\u011fundan \u015f\u00fcphelenilen veya antiplatelet tedavi alan travma hastalar\u0131nda trombosit fonksiyonunun izlenmesi i\u00e7in yatakba\u015f\u0131 trombosit fonksiyon \u00f6l\u00e7er cihazlar\u0131n rutin kullan\u0131m\u0131ndan ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (1C).<em><strong>(De\u011fi\u015fen \u00f6neri)<\/strong><\/em><\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">3. Doku oksijenasyonu, vol\u00fcm, s\u0131v\u0131 ve \u0131s\u0131<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Vol\u00fcm replasman\u0131 ve hedef kan bas\u0131nc\u0131<\/h5>\n\n\n\n<p><strong>\u00d6neri 13<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Travmay\u0131 takip eden ilk evrede, beyin kanamas\u0131 klinik kan\u0131t\u0131 yoklu\u011funda, maj\u00f6r kanama durdurulana kadar hedef sistolik kan bas\u0131nc\u0131 80\u201390 mmHg (ortalama arter bas\u0131nc\u0131 50\u201360 mmHg) olan k\u0131s\u0131tl\u0131 vol\u00fcm replasman stratejisinin kullan\u0131lmas\u0131 \u00f6neriliyor (1B). <strong><em>(Asl\u0131nda \u00f6neri \u00f6nceki k\u0131lavuz ile ayn\u0131 ama permisif hipotansiyon terimi kullan\u0131lmam\u0131\u015f)<\/em><\/strong><\/li>\n\n\n\n<li>\u015eiddetli TBI (GKS\u22648) olan hastalarda, ortalama arter bas\u0131nc\u0131n\u0131n \u226580 mmHg olarak s\u00fcrd\u00fcr\u00fclmesi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Vazopress\u00f6rler ve inotropik ajanlar<\/h5>\n\n\n\n<p><strong>\u00d6neri 14<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>K\u0131s\u0131tl\u0131 vol\u00fcm replasman stratejisi hedef kan bas\u0131nc\u0131na ula\u015fmazsa, hedef arter bas\u0131nc\u0131n\u0131 s\u00fcrd\u00fcrmek i\u00e7in s\u0131v\u0131lara ek olarak noradrenalin verilmesi \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Miyokardiyal disfonksiyon varl\u0131\u011f\u0131nda dobutamin inf\u00fczyonu \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">S\u0131v\u0131 tipi<\/h5>\n\n\n\n<p><strong>\u00d6neri 15<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanamal\u0131 hipotansif travma hastas\u0131nda %0,9 sodyum klor\u00fcr veya dengeli kristalloid sol\u00fcsyon kullan\u0131larak s\u0131v\u0131 tedavisine ba\u015flanmas\u0131 \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>\u015eiddetli kafa travmas\u0131 olan hastalarda Ringer laktat gibi hipotonik \u00e7\u00f6zeltilerden ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Hemostaz \u00fczerindeki olumsuz etkileri nedeniyle kolloid kullan\u0131m\u0131n\u0131n k\u0131s\u0131tlanmas\u0131 \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Eritrositler<\/h5>\n\n\n\n<p><strong>\u00d6neri 16<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Eritrosit transf\u00fczyonu gerekiyorsa, 70\u201390 g\/L&#8217;lik hemoglobin hedefi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">H\u00fccre kurtarma<\/h5>\n\n\n\n<p><strong>\u00d6neri 17<\/strong><\/p>\n\n\n\n<p>Kar\u0131n, pelvik veya toraks bo\u015flu\u011fundan \u015fiddetli kanama varl\u0131\u011f\u0131nda h\u00fccre kurtarman\u0131n d\u00fc\u015f\u00fcn\u00fclmesi \u00f6neriliyor (2B).<em><strong>(Yeni \u00f6neri)<\/strong><\/em><\/p>\n\n\n\n<h5 class=\"wp-block-heading\">Is\u0131 y\u00f6netimi<\/h5>\n\n\n\n<p><strong>\u00d6neri 18<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Is\u0131 kayb\u0131n\u0131 azaltmak i\u00e7in \u00f6nlemlerin erken uygulanmas\u0131n\u0131, ve normotermi sa\u011flamak ve normotermiyi s\u00fcrd\u00fcrmek i\u00e7in hipotermik hastan\u0131n \u0131s\u0131t\u0131lmas\u0131 \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">4. Kanaman\u0131n h\u0131zl\u0131 kontrol\u00fc<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Hasar kontrol cerrahi<\/h5>\n\n\n\n<p><strong>\u00d6neri 19<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hemorajik \u015fok, devam eden kanama belirtileri, koag\u00fclopati ve\/veya kombine abdominal vask\u00fcler ve pankreatik yaralanmalar ile ba\u015fvuran ciddi \u015fekilde yaralanm\u0131\u015f hastada hasar kontrol cerrahisi \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Hasar kontrol yakla\u015f\u0131m\u0131n\u0131 ba\u015flatmas\u0131 gereken di\u011fer fakt\u00f6rler, hipotermi, asidoz, eri\u015filemeyen b\u00fcy\u00fck anatomik yaralanma, zaman al\u0131c\u0131 prosed\u00fcrlere ihtiya\u00e7 olmas\u0131d\u0131r (1C).<\/li>\n\n\n\n<li>Yukar\u0131daki fakt\u00f6rlerden herhangi birinin yoklu\u011funda definitif cerrahi tedavi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Pelvik halka kapatma ve stabilizasyon<\/h5>\n\n\n\n<p><strong>\u00d6neri 20<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>\u015e\u00fcpheli bir pelvik k\u0131r\u0131k varl\u0131\u011f\u0131nda hayat\u0131 tehdit eden kanamay\u0131 s\u0131n\u0131rland\u0131rmak i\u00e7in hastane \u00f6ncesi ortamda bir pelvik ba\u011flay\u0131c\u0131n\u0131n destek olarak kullan\u0131lmas\u0131 \u00f6neriliyor (1C). <strong><em>(Yeni \u00f6neri)<\/em><\/strong><\/li>\n\n\n\n<li>Pelvik halkada ayr\u0131\u015fmas\u0131 olan hemorajik \u015foktaki hastalarda m\u00fcmk\u00fcn oldu\u011fu kadar erken d\u00f6nemde pelvik halkan\u0131n kapat\u0131lmas\u0131n\u0131 ve stabilizasyonu \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Embolizasyon, tamponlama, cerrahi ve aorta res\u00fcsitatif endovask\u00fcler balon okl\u00fczyonu (REBOA)<\/h5>\n\n\n\n<p><strong>\u00d6neri 21<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanama devam ederken ve\/veya anjiyoembolizasyon zaman\u0131nda ger\u00e7ekle\u015ftirilemedi\u011finde ge\u00e7ici ekstraperitoneal tampon \u00f6neriliyor. Gerekti\u011finde ekstraperitoneal tampon a\u00e7\u0131k abdominal cerrahi ile kombine edilebilir (1C).<\/li>\n\n\n\n<li>Komprese edilemeyen ya\u015fam\u0131 tehdit eden travmatik kanamas\u0131 olan hastalarda REBOA&#8217;n\u0131n, hemodinamik kollaps ile kanama kontrol\u00fc aras\u0131ndaki bo\u015flukta k\u00f6pr\u00fc g\u00f6revi g\u00f6rmesi i\u00e7in d\u00fc\u015f\u00fcn\u00fclmesi \u00f6neriliyor (2C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Lokal hemostatik \u00f6nlemler<\/h5>\n\n\n\n<p><strong>\u00d6neri 22&nbsp;<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Parankimal yaralanmalarla ili\u015fkili ven\u00f6z veya orta derecede arteriyel kanama i\u00e7in di\u011fer cerrahi \u00f6nlemlerle veya tamponla birlikte topikal hemostatik ajanlar\u0131n kullan\u0131lmas\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">5. Kanama ve koag\u00fclopatinin ba\u015flang\u0131\u00e7 tedavisi<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Antifbrinolitik ajanlar<\/h5>\n\n\n\n<p><strong>\u00d6neri 23<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Traneksamik asidin (TXA), kanamas\u0131 olan veya ciddi kanama riski ta\u015f\u0131yan travma hastas\u0131na m\u00fcmk\u00fcn olan en k\u0131sa s\u00fcrede, m\u00fcmk\u00fcnse hastaneye giderken ve yaralanmadan sonraki 3 saat i\u00e7inde 1 g y\u00fckleme dozu 10 dakikada, takiben 1 g 8 saat i\u00e7erisinde uygulanmas\u0131 \u00f6neriliyor (1A).<\/li>\n\n\n\n<li>TXA uygulamas\u0131n\u0131n viskoelastik de\u011ferlendirme sonu\u00e7lar\u0131n\u0131 beklememesi \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Koag\u00fclasyon deste\u011fi<\/h5>\n\n\n\n<p><strong>\u00d6neri 24<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Koag\u00fclasyonu desteklemek i\u00e7in takip ve \u00f6nlemlerin hastaneye yat\u0131\u015ftan hemen sonra ba\u015flat\u0131lmas\u0131 \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Ba\u015flang\u0131\u00e7 koag\u00fclasyon res\u00fcsitasyonu<\/h5>\n\n\n\n<p><strong>\u00d6neri 25<\/strong><\/p>\n\n\n\n<p>Masif kanama olmas\u0131 beklenen hastalar\u0131n ba\u015flang\u0131\u00e7 tedavisinde a\u015fa\u011f\u0131daki iki stratejiden biri \u00f6neriliyor:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Fibrinojen konsantresi veya kriyopresipitat ve ES <\/li>\n\n\n\n<li>\u0130htiyaca g\u00f6re en az 1:2 TDP\/ES oran\u0131nda TDP veya patojen-inaktive edilmi\u015f TDP (1C).<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Ayr\u0131ca y\u00fcksek trombosit\/ES oran\u0131 \u00f6neriliyor (2B).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">6. \u0130leri hedefe y\u00f6nelik koag\u00fclasyon y\u00f6netimi<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Hedefe y\u00f6nelik tedavi<\/h5>\n\n\n\n<p><strong>\u00d6neri 26<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Res\u00fcsitasyon \u00f6nlemlerinin, standart laboratuvar koag\u00fclasyon de\u011ferleri ve\/veya viskoelastik \u00f6l\u00e7\u00fcmler k\u0131lavuzlu\u011funda, amaca y\u00f6nelik bir strateji kullan\u0131larak s\u00fcrd\u00fcr\u00fclmesi \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Taze donmu\u015f plazmaya dayal\u0131 y\u00f6netim<\/h5>\n\n\n\n<p><strong>\u00d6neri 27<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>TDP\u2019ye dayal\u0131 bir koag\u00fclasyon res\u00fcsitasyon stratejisi kullan\u0131l\u0131yorsa, ilave TDP kullan\u0131m\u0131n\u0131n standart laboratuvar koag\u00fclasyon tarama parametreleri (PT ve\/veya aPTT&gt; normalin 1.5 kat\u0131 ve\/veya p\u0131ht\u0131la\u015fma fakt\u00f6r\u00fc eksikli\u011finin viskoelastik kan\u0131t\u0131) k\u0131lavuzlu\u011funda yap\u0131lmas\u0131 \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Fibrinojen konsantresi ve\/veya kriyopresipitat mevcutsa hipofibrinojeneminin d\u00fczeltilmesi i\u00e7in TDP kullan\u0131m\u0131ndan ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (1C). <strong><em>(Min\u00f6r de\u011fi\u015fiklik)<\/em><\/strong><\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Koag\u00fclasyon fakt\u00f6r\u00fc konsantresine dayal\u0131 y\u00f6netim<\/h5>\n\n\n\n<p><strong>\u00d6neri 28<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Koag\u00fclasyon fakt\u00f6r\u00fc konsantresine dayal\u0131 strateji kullan\u0131l\u0131yorsa, standart laboratuvar koag\u00fclasyon tarama parametreleri k\u0131lavuzlu\u011funda tedavi \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Fibrinojen seviyelerinin normal olmas\u0131 ko\u015fuluyla, viskoelastik metod kullan\u0131larak, gecikmi\u015f p\u0131ht\u0131la\u015fma ba\u015flang\u0131c\u0131n\u0131n kan\u0131tlar\u0131na dayanarak kanamal\u0131 hastaya protrombin kompleks konsantresi (PCC) verilmesi \u00f6neriliyor (2C).&nbsp;<\/li>\n\n\n\n<li>FXIII takibinin koag\u00fclasyon destek algoritmalar\u0131na dahil edilmesini ve FXIII&#8217;\u00fcn fonksiyonel FXIII eksikli\u011fi olan kanamal\u0131 hastalarda desteklenmesi \u00f6neriliyor (2C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Fibrinojen takviyesi<\/h5>\n\n\n\n<p><strong>\u00d6neri 29<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Maj\u00f6r kanamaya hipofibrinojenemi (i\u015flevsel fibrinojen eksikli\u011finin viskoelastik belirtileri veya plazma Clauss fibrinojen seviyesi \u22641,5 g\/L) e\u015flik ediyorsa fibrinojen konsantresi veya kriyopresipitat ile tedavi \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Ba\u015flang\u0131\u00e7ta 3-4 g&#8217;l\u0131k bir fibrinojen takviyesi \u00f6neriliyor. Bu, 15\u201320 tek don\u00f6r kriyopresipitat \u00fcnitesine veya 3\u20134 g fibrinojen konsantresine e\u015fde\u011fer oluyor. Tekrarlanan dozlar, viskoelastik \u00f6l\u00e7\u00fcm ve fibrinojen seviyelerinin laboratuvar de\u011ferleri k\u0131lavuzlu\u011funda yap\u0131lmal\u0131 (2C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Trombositler<\/h5>\n\n\n\n<p><strong>\u00d6neri 30<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanamas\u0131 devam eden travma hastalar\u0131nda trombosit say\u0131s\u0131n\u0131 50\u00d7109\/L&#8217;nin \u00fczerinde ve TBH&#8217;l\u0131 hastalarda 100\u00d7109\/L&#8217;nin \u00fczerinde tutmak i\u00e7in trombosit verilmesi \u00f6neriliyor (2C).<\/li>\n\n\n\n<li>Verilecekse, ba\u015flang\u0131\u00e7 dozu olarak d\u00f6rt ila sekiz tekli trombosit \u00fcnitesi veya bir aferez paketi \u00f6neriliyor (2B).&nbsp;<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Kalsiyum<\/h5>\n\n\n\n<p><strong>\u00d6neri 31<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Maj\u00f6r travmay\u0131 takiben ve \u00f6zellikle masif transf\u00fczyon s\u0131ras\u0131nda iyonize kalsiyum d\u00fczeylerinin izlenmesini ve normal aral\u0131kta tutulmas\u0131 \u00f6neriliyor (1C).&nbsp;<\/li>\n\n\n\n<li>Hipokalsemiyi d\u00fczeltmek i\u00e7in kalsiyum klor\u00fcr verilmesi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Rekombinant aktif koag\u00fclasyon fakt\u00f6r\u00fc VII<\/h5>\n\n\n\n<p><strong>\u00d6neri 32<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Rekombinant aktif koag\u00fclasyon fakt\u00f6r\u00fc VII&#8217;nin (rFVIIa) birinci basamak tedavi olarak kullan\u0131lmas\u0131 \u00f6nerilmiyor (1B).<\/li>\n\n\n\n<li>rFVIIa&#8217;n\u0131n off-label kullan\u0131m\u0131n\u0131n yaln\u0131zca, kanamay\u0131 kontrol etmeye y\u00f6nelik di\u011fer t\u00fcm giri\u015fimlere, sistemik homeostaz ve geleneksel hemostatik \u00f6nlemlerin kullan\u0131m\u0131na ra\u011fmen maj\u00f6r kanama ve travmatik koag\u00fclopati devam ederse d\u00fc\u015f\u00fcn\u00fclmesi \u00f6neriliyor (2C).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">7. Antitrombotik ajanlar\u0131n y\u00f6netimi<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">K vitamini ba\u011f\u0131ml\u0131 oral antikoag\u00fclanlar\u0131n tersine \u00e7evrilmesi<\/h5>\n\n\n\n<p><strong>\u00d6neri 33<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanamal\u0131 travma hastas\u0131nda, K vitamini ba\u011f\u0131ml\u0131 oral antikoag\u00fclanlar\u0131n hem PCC hem de 5-10 mg i.v. fitomenadion (K1 vitamini) ile tersine \u00e7evrilmesi \u00f6neriliyor (1A).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Direkt oral antikoag\u00fclanlar\u0131n y\u00f6netimi &#8211; fakt\u00f6r Xa inhibit\u00f6rleri<\/h5>\n\n\n\n<p><strong>\u00d6neri 34<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Bu ajanlardan biriyle tedavi edilen veya tedavi edildi\u011finden \u015f\u00fcphelenilen hastalarda apiksaban, edoksaban veya rivaroksaban gibi oral direkt anti fakt\u00f6r Xa ajanlar\u0131n\u0131n plazma d\u00fczeylerinin \u00f6l\u00e7\u00fclmesi \u00f6neriliyor (2C).<\/li>\n\n\n\n<li>Anti-Xa aktivite \u00f6l\u00e7\u00fcm\u00fcn\u00fcn spesifik ajan i\u00e7in kalibre edilmesi \u00f6neriliyor. M\u00fcmk\u00fcn veya mevcut de\u011filse, g\u00fcvenilir bir alternatif olarak d\u00fc\u015f\u00fck molek\u00fcler a\u011f\u0131rl\u0131kl\u0131 heparin (LMWH) ile kalibre edilmi\u015f anti-Xa testleri \u00f6neriliyor (Grade 2C).<\/li>\n\n\n\n<li>Bir apiksaban veya rivaroksaban etkisi alt\u0131nda hayat\u0131 tehdit eden kanama varsa, \u00f6zellikle TBH&#8217;l\u0131 hastalarda, andexanet alfa ile geri d\u00f6nd\u00fcrme \u00f6neriliyor (2C). <em><strong>(Yeni \u00f6neri)<\/strong><\/em><\/li>\n\n\n\n<li>Andexanet alfa yoksa veya edoxaban alan hastalarda PCC (25\u201350 \u00dc\/kg) uygulamas\u0131 \u00f6neriliyor (2C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Direkt oral antikoag\u00fclanlar\u0131n y\u00f6netimi &#8211; direkt trombin inhibit\u00f6rleri<\/h5>\n\n\n\n<p><strong>\u00d6neri 35<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Dabigatran ile tedavi edilen veya tedavi edildi\u011fi d\u00fc\u015f\u00fcn\u00fclen hastalarda seyreltilmi\u015f trombin zaman\u0131 kullan\u0131larak dabigatran plazma d\u00fczeylerinin \u00f6l\u00e7\u00fclmesi \u00f6neriliyor (2C).<\/li>\n\n\n\n<li>\u00d6l\u00e7\u00fcm m\u00fcmk\u00fcn veya mevcut de\u011filse, dabigatran varl\u0131\u011f\u0131n\u0131n kalitatif bir tahminini g\u00f6rebilmek i\u00e7in standart trombin zaman\u0131n\u0131n \u00f6l\u00e7\u00fclmesi \u00f6neriliyor (2C).<\/li>\n\n\n\n<li>Dabigatran kullananlarda kanama hayat\u0131 tehdit ediyorsa idarucizumab (i.v. 5 g) ile tedavi \u00f6neriliyor (1C).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Antiplatelet ajanlar<\/h5>\n\n\n\n<p><strong>\u00d6neri 36<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Antiplatelet ajanlarla tedavi edilen ve devam eden kanamas\u0131 olan hastalarda rutin trombosit transf\u00fczyonundan ka\u00e7\u0131n\u0131lmas\u0131 \u00f6neriliyor (1C). <strong><em>(Yeni \u00f6neri) (De\u011fi\u015fen \u00f6neri)<\/em><\/strong><\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">8. Tromboprofilaksi&nbsp;<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Tromboprofilaksi<\/h5>\n\n\n\n<p><strong>\u00d6neri 37<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hasta immobil ve kanama riski varsa aral\u0131kl\u0131 pn\u00f6matik kompresyon ile mekanik tromboprofilaksiye erken ba\u015flanmas\u0131 \u00f6neriliyor (1C).<\/li>\n\n\n\n<li>Kanama kontrol alt\u0131na al\u0131nd\u0131ktan sonraki 24 saat i\u00e7inde ve hasta mobilize olana kadar farmakolojik ve aral\u0131kl\u0131 pn\u00f6matik kompresyon tromboprofilaksi kombine olarak \u00f6neriliyor (1B).<\/li>\n\n\n\n<li>Dereceli kompresyon \u00e7oraplar\u0131n\u0131n tromboprofilaksi i\u00e7in kullan\u0131lmas\u0131 \u00f6nerilmiyor (1C).<\/li>\n\n\n\n<li>Tromboprofilaksi i\u00e7in inferior vena kava flterlerinin rutin kullan\u0131m\u0131 \u00f6nerilmiyor (1C).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">9. K\u0131lavuzun uygulanmas\u0131 ve kalite kontrol<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">K\u0131lavuzun uygulanmas\u0131<\/h5>\n\n\n\n<p><strong>\u00d6neri 38<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanamal\u0131 travma hastas\u0131n\u0131n y\u00f6netimi i\u00e7in kan\u0131ta dayal\u0131 k\u0131lavuzlar\u0131n yerel olarak uygulanmas\u0131 \u00f6neriliyor (Derece 1B).<\/li>\n<\/ul>\n\n\n\n<h5 class=\"wp-block-heading\">Kanama kontrol\u00fc ve sonlan\u0131m\u0131n de\u011ferlendirilmesi<\/h5>\n\n\n\n<p><strong>\u00d6neri 39<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kanama kontrol\u00fc ve sonucunun temel \u00f6l\u00e7\u00fctlerini de\u011ferlendirmek i\u00e7in yerel klinik kalite ve g\u00fcvenlik y\u00f6netim sistemlerinin parametreler i\u00e7ermesi \u00f6neriliyor (1B).<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n\n\n\n<p><\/p>\n\n\n\n<p><strong>Kaynak : <\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Gr\u00f8nlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27(1):80. doi: 10.1186\/s13054-023-04327-7. PMID: 36859355; PMCID: PMC9977110.<\/li>\n\n\n\n<li>Treskes K, Saltzherr TP, Edwards MJR, Beuker BJA, Van Lieshout EMM, Hohmann J, Luitse JSK, Beenen LFM, Hollmann MW, Dijkgraaf MGW, et al. Refining the criteria for immediate total-body CT after severe trauma. Eur Radiol. 2020;30(5):2955\u201363.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Travma sonras\u0131 kanama ve buna ba\u011fl\u0131 travmatik koag\u00fclopati, uygun ve zaman\u0131nda tan\u0131n\u0131p m\u00fcdahale edilmedi\u011fi takdirde, potansiyel olarak \u00f6nlenebilir \u00f6l\u00fcm\u00fcn \u00f6nde gelen nedenleri&hellip;<\/p>\n","protected":false},"author":883,"featured_media":648,"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":[1,10010,10014],"tags":[10047,10110,10109,10046],"class_list":["post-645","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-slider","category-akademik-blog-yazisi","tag-kanama","tag-kilavuz","tag-koagulopati","tag-travma"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts\/645","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/users\/883"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/comments?post=645"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts\/645\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/media\/648"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/media?parent=645"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/categories?post=645"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/tags?post=645"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}