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Interdisziplinäres Traumamanagement

Update 3 Jahre nach Implementierung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung

Interdisciplinary management of trauma patients

Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries

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An Erratum to this article was published on 17 January 2015

Zusammenfassung

Hintergrund

Drei Jahre nach Veröffentlichung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung müssen die enthaltenen Kernaussagen weiterhin implementiert werden.

Ziel der Arbeit

Der vorliegende Beitrag soll einerseits einige der wesentlichen Kernaussagen der S3-Leitlinie repetieren und andererseits einen Überblick über neuere wissenschaftliche Studien geben.

Material und Methoden

In einer selektionierten Literaturrecherche wurden neue Studien zu den Themen Atemwegsmanagement, traumaassoziierter Herz-Kreislauf-Stillstand, Schockklassifikationen, Gerinnungstherapie, Ganzkörpercomputertomographie sowie Luftrettung und Zielklinik identifiziert. Die dabei gewonnenen Erkenntnisse werden vor dem Hintergrund der bestehenden Kernaussagen der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung diskutiert.

Ergebnisse

Die in der S3-Leitlinie bestehenden Empfehlungen zum Atemwegsmanagement sind weiterhin aktuell. Jedoch sollten Empfehlungen zur Beurteilung eines schwierigen Atemwegs (z. B. „LEMON law“) ergänzt werden. Als wesentlicher Qualitätsparameter wird zukünftig der „first pass success“ (Intubationserfolg im 1. Versuch) berücksichtigt werden müssen. Die Videolaryngoskopie stellt hierbei ein zukunftweisendes Instrument zur Umsetzung dieses Ziels dar. Aktuell ermittelte Lernkurven für die endotracheale Intubation und supraglottische Atemwegshilfen sollten bei der Erstellung von Qualifikationsanforderungen berücksichtigt werden. Lebensrettende invasive Notfalltechniken müssen prähospital durchgeführt werden und verlängern nicht die Gesamtversorgungsdauer schwerverletzter Patienten bis zum Abschluss der Schockraumphase. Die Behandlungsergebnisse bei traumaassoziierten Herz-Kreislauf-Stillständen sind besser als erwartet. Aktuell entwickelte Reanimationsalgorithmen für Traumapatienten müssen implementiert werden. Die „Prehospital-trauma-life-support“(PHTLS)/“Advanced-trauma-life-support“(ATLS)-Schockkriterien haben sich als nicht realitätsnah herausgestellt, daher schlagen neuere Untersuchungen die Beachtung der Laktatkonzentration, der Laktat-Clearance und des Basendefizits für die Evaluation eines Schockzustands im Schockraum vor. Im Gerinnungsmanagement hat sich Tranexamsäure als einfach zu applizierende, sichere und effektive antifibrinolytische Substanz herausgestellt, deren Einsatz jedoch nicht nur den am schwersten verletzten Patienten vorbehalten sein sollte. Zahlreiche Studien legen einen positiven Effekt der Ganzkörpercomputertomographie auf die Versorgungszeit und das Überleben nahe. Ungeklärt sind hierbei die Indikatoren, die die Notwendigkeit einer Durchführung einer Ganzkörpercomputertomographie anzeigen. Weitere Untersuchungen unterstützen die Einschätzung eines positiven Effekts der Luftrettung auf das Behandlungsergebnis von Traumapatienten.

Schlussfolgerung

Die in der S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“ bestehenden Empfehlungen zum interdisziplinären Traumamanagement sollten in den klinischen Alltag übertragen werden. Daneben ist die Kenntnis neuerer wissenschaftlicher Studien für den Anästhesisten und Notarzt wichtig, um die Kernaussagen der S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“ adäquat umsetzen zu können.

Abstract

Background

The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries.

Aim

This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies.

Material and methods

In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations.

Results

The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients.

Conclusion

The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. B. Donaubauer, J. Fakler, A. Gries, U.X. Kaisers, C. Josten, M. Bernhard geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland

    B. Donaubauer & U.X. Kaisers

  2. Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland

    J. Fakler & C. Josten

  3. Zentrale Notaufnahme, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland

    A. Gries & M. Bernhard

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  1. B. Donaubauer
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Donaubauer, B., Fakler, J., Gries, A. et al. Interdisziplinäres Traumamanagement. Anaesthesist 63, 852–864 (2014). https://doi.org/10.1007/s00101-014-2375-y

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