Zusammenfassung
Jede vermutete Abdominalverletzung sollte schnellstmöglich in eine geeignete Klinik eingeliefert werden. Mit der notfallmedizinischen Erstuntersuchung ist eine Lebensbedrohung mit der Konsequenz einer notfallmäßig blutstillenden Operation zu identifizieren.
Bei penetrierenden Verletzungen mit möglicher Penetration des Peritoneums sollte bei Kreislaufstabilität diese laparoskopisch ausgeschlossen werden. Bei vorliegender Penetration sollte eine Intestinalverletzung durch operative Exploration ausgeschlossen bzw. behandelt werden. Beim stumpfen Abdominaltrauma steht die klinische Untersuchung an erster Stelle, welche jedoch bei einer Sensitivität bis zu 82% und einer Spezifität von bis zu 45% alleine nicht ausreichend verlässlich ist.
Für die weitere Diagnostik hat heute die Ultraschalluntersuchung die diagnostische Peritoneallavage insbesondere im deutschsprachigen Raum vollständig ersetzt. Diese sollte neben der Diagnostik freier intraabdomineller Flüssigkeit auch Organläsionen erfassen und wiederholt durchgeführt werden. Damit lässt sich eine Genauigkeit von bis zu 96% mit einer Spezifität von 99,8% und Sensitivität von 72,1% erzielen. Die CT-Diagnostik mit und ohne i.v. Kontrastmittel stellt den Goldstandard der apparativen Diagnostik dar mit einer hohen Sensitivität und Spezifität von 97,2% bzw. 94,7%. Falsch-negative Befunde kommen weiterhin bei Hohlorganverletzungen vor und erfordern weitere engmaschige klinische, sonographische und ggf. computertomographische Kontrolluntersuchungen.
Schließlich kommt, insbesondere bei polytraumatisierten Patienten der intraabdominellen Druckmessung bei sich entwickelndem Organversagen eine zunehmende Bedeutung zu, mit der Konsequenz der abdominellen Dekompression ab einem Druck von 20 mmHg zu erwägen.
Abstract
In case of suspected intra-abdominal injury, fast transport of the patient to a suitable hospital is of high priority. The initial clinical examination aims at identifying patients with potentially life-threatening bleeding that require emergency surgery. In patients with penetrating trauma, laparoscopy is favoured to exclude suspected perforation of the peritoneum. If a peritoneal perforation is identified, exploratory laparotomy is recommended to exclude or treat lacerations of the hollow viscus. Although clinical examination should be performed its sensitivity and specificity of up to 82% and 45%, respectively, are not sufficient as the sole screening method. For the further diagnostic workup, diagnostic peritoneal lavage has been completely replaced by abdominal ultrasound examination in Germany and many other countries. Focussing not only on the detection of free abdominal fluid but also searching for parenchymal organ lesions and performing repeated examinations increases accuracy up to 96%, with specificity of 99.8% and sensitivity of 72.1%. Computed abdominal tomography with a helical scanner with and without intravenous contrast media is currently the gold standard of imaging techniques to identify traumatic abdominal injuries. A sensitivity of 97.2% and specificity of 94.7% can be achieved. False negative findings must be expected with hollow organ injuries. Serial clinical and ultrasound examinations as well as lab testing in conjunction with repeated CT may help to identify such lesions. Increased intra-abdominal pressure (IAP) with consecutive abdominal compartment syndrome and multiple organ dysfunction is a delayed complication from conditions such as severe intra-abdominal bleeding, major bleeding from pelvic ring fractures, and profuse fluid resuscitation. The IAP should be measured routinely in patients at risk, and decompression laparotomy may be indicated with pressures of higher than 20 mmHg.
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Nast-Kolb, D., Bail, H.J. & Taeger, G. Moderne Diagnostik des Bauchtraumas. Chirurg 76, 919–926 (2005). https://doi.org/10.1007/s00104-005-1092-0
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DOI: https://doi.org/10.1007/s00104-005-1092-0
Schlüsselwörter
- Bauchtrauma
- Diagnostik
- Ultraschalluntersuchung
- Computertomographie
- Intraabdominelle Druckmessung
- Laparoskopie
- Peritoneallavage