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Entscheidungsfindung und Prioritäten der operativen Behandlungsstrategie während und nach der Schockraumversorgung

Decisions and priorities of operative treatment during shock room treatment

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Zusammenfassung

Fragestellung.

Die in der Literatur vorgeschlagenen Therapiestrategien und Maßgaben zur operativen Verfahrenswahl zur Versorgung polytraumatisierter Patienten innerhalb der ersten 24 h werden evaluiert.

Methodik.

Klinische Studien wurden über systematische Literatursuchen (Medline, Cochrane und konventionelle Suche) und Klassifikation hinsichtlich der Evidenzgüte (Level 1–5 nach Oxford-Schema) kontrolliert.

Ergebnisse.

Therapiemaßnahmen beim polytraumatisierten Patienten werden in 4 Abschnitte (Akut-, Primär-, Sekundär- und Tertiärphase) eingeteilt. In der akuten Phase hat die Versorgung von Massenblutungen Priorität, welche zeitlich mit der Behandlung intrakranieller Verletzungen abzustimmen ist. In der anschließenden Primärphase erfolgt die operative Versorgung in der Reihenfolge Schädel → Mittelgesicht → Wirbelsäule → Abdomen → Extremitäten, wobei ein simultanes Vorgehen möglich ist. Eine primäre Definitivversorgung der Verletzungen ist anzustreben, allerdings sollte bei instabilen Patienten oder unsicherem Allgemeinzustand („Borderline-Patienten“) zur Minimierung des Operationstraumas eine primär temporäre Therapie durchgeführt werden.

Schlussfolgerung.

Der klinische Verlauf nach Polytrauma wird durch drei wesentliche Faktoren beeinflusst. Zum initialen Verletzungsbild („first hit“) kann sich die Systembelastung der chirurgischen Eingriffe („second hit“) addieren. Als dritter Belastungsfaktor ist die individuelle biologische Konstitution des Patienten zu werten, zur Beurteilung kann hier das Monitoring mittels immunologischer Parameter hilfreich sein.

Abstract

Objective.

Concepts for optimal surgical treatment of the patient with blunt multiple injuries are being evaluated on the basis of the current literature.

Methods.

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).

Results.

The posttraumatic clinical course is divided into four different periods: acute-, primary-, secondary- und tertiary period. The first and second period are important for life saving surgery and the stabilization of major fractures. After the cardiorespiratory systems have been stabilized, the following priorities have been formulated: head, face, spine, abdomen, extremities. To restrict the degree of operative burden on the patient it appears to be necessary to limit the duration of initial surgery to less than 6 hours. In patients at high risk to develop posttraumatic complications—”borderline patients”—it appears safer to perform only temporary fixation of major fractures.

Conclusions.

Three different factors determine the clinical course after polytrauma: Trauma represents the first hit, followed by the therapy-induced burden (second hit). In addition, the third hit is represented by the individual response. An evaluation of the clinical status by immunologic monitoring can be performed in order to assess the patient’s status.

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  1. Unfallchirurgische Klinik, Medizinische Hochschule Hannover

    H. C. Pape, F. Hildebrand & C. Krettek

  2. Unfallchirurgische Klinik, Medizinische Hochschule, Carl-Neuberg-Straße 1, 30625, Hannover

    H. C. Pape

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Pape, H.C., Hildebrand, F. & Krettek, C. Entscheidungsfindung und Prioritäten der operativen Behandlungsstrategie während und nach der Schockraumversorgung. Unfallchirurg 107, 927–936 (2004). https://doi.org/10.1007/s00113-004-0848-1

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