Additive notärztliche Maßnahmen beim traumaassoziierten Herz-Kreislauf-Stillstand

Zusammenfassung

Einleitung

Mehr als die Hälfte aller traumaassoziierten Todesfälle ereignen sich prähospital. Bisher fehlt es an Studien über mehrjährige Zeiträume zur Durchführung additiver traumaspezifischer Reanimationsmaßnahmen (z. B. Pleuraraumentlastung, Perikardiozentese, Tourniquet, Beckenschlinge) beim traumaassoziierten Herz-Kreislauf-Stillstand. Die vorliegende Kohortenstudie analysiert rechtsmedizinische Obduktionsergebnisse von am Ereignisort trotz Reanimationsmaßnahmen verstorbenen Traumapatienten bezüglich additiver Maßnahmen sowie die Vermeidbarkeit dieser Sterbefälle.

Material und Methoden

In der retrospektiven Datenauswertung der Obduktionsprotokolle aus Leipzig und Chemnitz von 2011 bis 2017 wurden die traumaassoziierten Sterbefälle mit professionellen prähospitalen Reanimationsversuchen und Todeseintritt vor Ort, auf dem Transport oder kurz nach Krankenhausaufnahme identifiziert. Erfasst wurden epidemiologische Parameter, prähospital durchgeführte Maßnahmen und das jeweilige Verletzungsmuster, um retrospektiv mithilfe eines strukturierten Delphi-Verfahrens die Frage der Vermeidbarkeit (potenziell/definitiv vermeidbar vs. nicht vermeidbar) und möglicher Managementfehler strukturiert zu beantworten.

Ergebnisse

Aus einem Obduktionsvolumen von 3795 Fällen konnten 154 traumaassoziierte Todesfälle mit prähospitalen Reanimationsmaßnahmen identifiziert werden (Anteil männlicher Patienten: 70,1 %; Alter: 48 ± 21 Jahre). Die Patienten verstarben meistens noch am Ereignisort (84,4 %), seltener auf dem Transport (2,6 %) oder direkt nach Klinikaufnahme (13,0 %). Bei lediglich 23 Patienten (14,9 %) wurden 25 additive traumaspezifische Reanimationsmaßnahmen (Pleuradekompression: 80 %, Perikardiozentese: 8 %, Beckenstabilisierung: 12 %) durchgeführt. In mehr als einem Drittel der Fälle fanden sich Managementfehler und in 12,3 % potenziell vermeidbare Todesfälle, insbesondere nach penetrierenden Thoraxverletzungen.

Diskussion

Der Anteil von durch traumaspezifische Reanimationsmaßnahmen potenziell positiv zu beeinflussenden traumaassoziierten Reanimationen scheint im Flächenland Sachsen an den Standorten Leipzig und Chemnitz vergleichbar zu Voruntersuchungen in Berlin zu sein. Die weitere Sensibilisierung für die Notwendigkeit prähospitaler traumaspezifischer additiver Maßnahmen beim traumaassoziiertem Herz-Kreislauf-Stillstand in der Aus- und Weiterbildung erscheint notwendig.

Abstract

Introduction

More than half of all traumatic deaths happen in prehospital settings. Until now, there have been no long-term studies examining the actual additive treatment during trauma-associated cardiopulmonary resuscitation (tCPR), including pleural decompression, pericardiocentesis, tourniquets and external stabilization of the pelvis. The present cohort study evaluated forensic autopsy reports of trauma deaths occurring at the scene with respect to additive actions in preclinical tCPR as well as the potentially preventable nature of the individual death cases.

Material and methods

All autopsy protocols from the Institutes of Legal Medicine in Leipzig and Chemnitz, Germany within the years 2011–2017 were retrospectively examined and all trauma deaths with professional prehospital tCPR at the scene, during transport or shortly after arriving at the emergency room were analyzed. In addition to epidemiological parameters all forms of medical procedure performed by emergency physicians and the injury patterns were recorded. Thus, the questions whether any of the trauma deaths were preventable and if failures in work-flow management were evident could be retrospectively answered through a structured Delphi method.

Results

Overall, 3795 autopsy protocols were listed containing 154 trauma cases (4.1%) with various preclinical tCPR attempts (male patients 70.1%; mean age 48 ± 21 years). Most of them died at the accident site (84.4%), some during transport (2.6%) or directly after admission to a hospital (13.0%). Only 23 patients (14.9%) received 25 additional interventions exceeding the normal scope (pleural decompression 80.0%, pericardiocentesis 8.0% and external stabilization of the pelvis 12.0%). A relevant number of potentially reversible causes for trauma-associated cardiac arrest was determined. There were deficits in the performance of pleural decompression in cases of tension pneumothorax. Even if isolated traumatic hemopericardium was a rare occurrence in the examined cases, the rate of pericardiocentesis was still too low. Also, more focus needs to be placed on provisional external pelvic stabilization of trauma patients which was performed too rarely even though an instable pelvic ring was apparent during the postmortem external examination. None of the cases received a rescue thoracotomy even if a few patients might have derived benefit from this and none of the cases showed injury patterns with tourniquet indications. Furthermore, no single case of death due to incorrect or missing airway management was determined. Errors in work-flow management were found in 37.0% and potentially preventable deaths occurred cumulatively in 12.3% of the cases. The potentially preventable deaths were particularly related to penetrating chest injuries caused by a sharp force.

Discussion

The percentage of patients who might benefit from additive treatment implemented in tCPR efforts was shown to be equal between the local situations in Leipzig and Chemnitz compared to previous reports in Berlin. A need for optimizing the professional resuscitation process still remains as not all reversible causes were appropriately addressed. Further training and education should intensively address the mentioned deficits and continuous awareness of necessary additional medical procedures in the preclinical setting in cases of traumatic cardiac arrest is inevitable. Cooperation with forensic institutes can help to impart particular issues and treatment options of emergency medicine in cases of potentially reversible causes of traumatic cardiac arrest.