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Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Hintergrund und Kernaussagen der interdisziplinären S3-Leitlinie Polytrauma

Emergency anesthesia, airway management and ventilation in major trauma

Background and key messages of the interdisciplinary S3 guidelines for major trauma patients

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Zusammenfassung

Beim polytraumatisierten Patienten besteht bei Apnoe oder Schnappatmung (Atemfrequenz  < 6) prähospital die Indikation zur Einleitung einer Notfallnarkose, endotrachealen Intubation (ETI) und Beatmung. Weitere Indikationen sind eine Hypoxie [pulsoxymetrisch gemessene Sauerstoffsättigung (SpO2)  < 90% trotz Sauerstoffgabe und nach Ausschluss eines Spannungspneumothorax], ein schweres Schädel-Hirn-Trauma [Glasgow Coma Scale (GCS)  < 9], eine traumaassoziierte hämodynamische Instabilität (systolischer Blutdruck < 90 mmHg) und ein schweres Thoraxtrauma mit respiratorischer Insuffizienz (Atemfrequenz  > 29). Die Narkoseeinleitung wird nach Präoxygenierung als „rapid sequence induction“ (Analgetikum, Hypnotikum, Muskelrelaxans) durchgeführt. Auf Etomidat sollte aufgrund der assoziierten Nebenwirkungen auf die Nebennierenfunktion verzichtet werden; dabei stellt Ketamin eine gute Alternative dar. Die Überwachung der Notfallnarkose und der Atemwegssicherung erfolgt mittels EKG, Blutdruckmessung und Pulsoxymetrie. Eine Kapnographie ist prähospital bzw. innerklinisch zu Tubuslage-, Tubusdislokation- und Beatmungskontrolle zwingend anzuwenden. Vor dem Hintergrund, dass beim Traumapatienten regelhaft mit einem schwierigen Atemweg zu rechnen ist, müssen alternative Methoden und innerklinisch eine Fiberoptik zur Atemwegssicherung vorgehalten werden. Spätestens nach mehr als drei erfolglosen Intubationsversuchen sollten diese alternativen Methoden zur Beatmung bzw. Atemwegssicherung in Betracht gezogen werden. Notärztliches Personal muss regelmäßig in der Durchführung einer Notfallnarkose, der ETI und der alternativen Methoden zur Atemwegssicherung trainiert werden. Innerklinisch werden ETI, Notfallnarkose und Beatmung durch trainiertes und erfahrenes anästhesiologisches Personal durchgeführt. Bei erwartet schwieriger Narkoseeinleitung und/oder ETI supervidiert und/oder führt innerklinisch ein anästhesiologischer Facharzt diese Verfahren durch. Als Beatmungsziel wird eine Normoventilation angestrebt. Ab der Schockraumphase wird die Beatmung durch engmaschige arterielle Blutgasanalysen kontrolliert und gesteuert. Zur Atemwegssicherung wird die Halswirbelsäule mittels manueller „In-line“-Stabilisation unter temporärer Aufhebung der Immobilisation mittels Halswirbelsäulen(HWS)-Immobilisationsschiene stabilisiert.

Abstract

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate  < 6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (SpO2  < 90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)  < 9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)  < 90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate  > 29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

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Notes

  1. Pulsoxymetrisch gemessene Sauerstoffsättigung.

  2. Wert für den systolischen Blutdruck.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: siehe S3-Leitlinienerklärung Interessenkonflikt (www.awmf.org).

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Authors and Affiliations

  1. Zentrale Notaufnahme/Notaufnahmestation, Universitätsklinikum Leipzig, Leipzig, Deutschland

    M. Bernhard

  2. Unfall- und Wiederherstellungschirurgie, Ernst-Moritz-Arndt-Universität, Greifswald, Deutschland

    G. Matthes

  3. Klinik für Unfallchirurgie und Orthopädie, Unfallkrankenhaus Berlin, Berlin, Deutschland

    G. Matthes

  4. Chirurgische Klinik und Poliklinik, Klinikum der Universität, München-Innenstadt, Deutschland

    K.G. Kanz

  5. Klinik für Unfallchirurgie, Universitätsklinikum Essen, Essen, Deutschland

    C. Waydhas & M. Fischbacher

  6. Klinik für Anästhesiologie, Operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinik am Eichert, Kliniken des Landkreises Göppingen gGmbH, Göppingen, Deutschland

    M. Fischer

  7. Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland

    B.W. Böttiger D.E.A.A., F.E.S.C., F.E.R.C.

Authors
  1. M. Bernhard
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  2. G. Matthes
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  3. K.G. Kanz
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  4. C. Waydhas
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  5. M. Fischbacher
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  6. M. Fischer
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  7. B.W. Böttiger D.E.A.A., F.E.S.C., F.E.R.C.
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Correspondence to B.W. Böttiger D.E.A.A., F.E.S.C., F.E.R.C..

Additional information

Michael Bernhard und Gerrit Matthes waren zu gleichen Teilen als Erstautoren an der Erstellung des Manuskripts beteiligt. Die Publikation erfolgt parallel in Der Anaesthesist und Der Unfallchirurg.

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Bernhard, M., Matthes, G., Kanz, K. et al. Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma. Anaesthesist 60, 1027–1040 (2011). https://doi.org/10.1007/s00101-011-1957-1

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