Untersuchungen zur Effizienz der notärztlichen Therapie bei Patienten mit Schädel-Hirn- bzw. Polytrauma Ein Beitrag zur Qualitätssicherung in der Notfallmedizin

Zusammenfassung

Es existieren bislang nur sehr wenige prospektive Untersuchungen über die Effizienz notärztlicher Maßnahmen bei Schädel-Hirn- und Polytraumatisierten. In der vorliegenden Arbeit wurde am Beispiel von 179 durch Notarztdienste versorgten Traumapatienten untersucht, inwieweit vorgegebene Standards in die Praxis umgesetzt wurden und die Qualität der Primärversorgung das Outcome der Patienten beeinflußte. Verglichen mit älteren Arbeiten ist die Qualität der notärztlichen Versorgung deutlich verbessert worden, jedoch gibt es immer noch verbesserungswürdige Punkte. So zeigte sich, daß 29% der Patienten mit qualitativ und/oder quantitativ nicht ausreichenden venösen Zugängen zur Aufnahme kamen, und 17% keine angemessene Volumensubstitution erhalten hatten. Bei adäquater Volumentherapie verstarben in allen Gruppen deutlich weniger Patienten als bei unzureichendem Volumenersatz, bei den isolierten Schädel-Hirn-Traumata war der Unterschied signifikant. 167 Patienten (93%) waren vom Norarzt intubiert worden und in 150 Fällen konnte die Beatmungstherapie mit suffizient eingestuft werden. Die Letalitätsrate war bei isoliertem SHT und suffizienter Beatmung signifikant niedriger als bei insuffizienter Beatmung. Lediglich 54% der Patienten wurden auf einer Vakuummatratze gelagert, und von 150 kreislaufstabilen Patienten waren nur 24% zusätzlich mit 30° erhöhtem Oberkörper gelagert worden. Die meisten Patienten wurden ausschließlich sediert (61%) und nur 41 (23%) erhielten Analgetika. Für das isolierte SHT zeigte sich, daß GCS-Werte von 3 und 4 mit sehr hohen Letalitätsraten einhergingen (59% bzw. 69%), daß jedoch bei Werten zwischen 5 und 8 eine signifikante Abhängigkeit des Überlebens des Traumas von der Qualität der notärztlichen Versorgung bestand (82,5% versus 40%). Insgesamt lag die Letalität in der Gruppe der suffizient versorgten Patienten bei 24% und somit signifikant niedriger als in der insuffizient versorgten Gruppe (62%).

Abstract

For cardio-pulmonary resuscitation there are standardized treatment concepts, but there have been few prospective investigations examining the efficacy of prehospital advanced trauma life support and its effect on the outcome in patients with severe head injury and multiple trauma treated within the German emergency system. The results of this study underline the importance of intensive prehospital treatment and highlight some problems that should be taken into account in future in the training of emergency physicians.

Methods. A total of 179 patients with cerebral trauma were investigated. Data obtained included demographic and logistic data of the patients and the emergency physicians, diagnoses and treatment at the scene of the accident and state of the patient on admission in each case. Having divided the patients into three groups by severity of the trauma, we distinguished between sufficient and insufficient treatment and assessed infusion therapy, ventilatory support, positioning and immobilization, and analgesic and sedative therapy. For statistical analysis of the data we used χ²-test and Fisher's exact test. P<0.05 was considered significant.

Results. There were 102 patients who had sustained a cerebral trauma without other life-threatening lesions (score 1), 40 with multiple trauma (score 2) and 37 with multiple trauma (score 3). On average 2.4 IV lines were established and the patients received 1186±765 cc of crystalloid in addition to 801±411 cc of colloid fluids. In all groups, patients who received adequate infusion therapy had a better outcome; even in the group with score 1 significantly fewer had a fatal outcome. In all, 167 (93%) patients had endotracheal tubes placed, and in 150 cases (84%) ventilatory therapy was considered sufficient. The proportion of score 1 patients with sufficient ventilatory support who had a fatal outcome was significantly lower than that in the group with insufficient treatment. In patients with multiple trauma we could not separate the benefits of sufficient respiratory therapy and infusion therapy. In only 54% of the cases a vacuum mattress was used and in only 41% the patients were positioned with the upper part of the body elevated by 30°. These were 28 patients (16%) who received neither analgesics nor sedatives. Regardless of the quality of prehospital treatment of isolated head injury, a Glasgow Coma Scale (GCS) score lower than 5 involved a very high mortality and all patients with a GCS score of 9 or more survived. In the group with GCS scores between 5 and 8, however, significantly more of the patients who received adequate treatment survived (82.5% vs 40%).

Conclusions. The present study confirms that sufficient advanced trauma life support can improve the outcome of trauma victims with cerebral trauma. Adequate infusion and respiratory therapy reduce the mortality among such patients significantly. In patients with multiple trauma a clear positive effect of generous infusion therapy also is evident. The clearest effect of sufficient prehospital treatment is seen in patients with isolated cerebral trauma and a GCS score between 5 and 8. These results demonstrate the importance of advanced trauma life support and show emphatically that the so-called scoop-and-run strategy should be abandoned when resources are available for extended preclinical emergency treatment. On the other hand, we detected some problem areas in the prehospital treatment of trauma victims, such as positioning, immobilization and drug therapy with analgesics and sedatives. These findings allow us to pinpoint specific points that should be stressed in the training of emergency physicians and paramedics.