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Zivile Explosionstraumata – ein unterschätztes Problem?

Ergebnisse einer retrospektiven Analyse aus dem TraumaRegister DGU®

Civilian blast injuries: an underestimated problem?

Results of a retrospective analysis of the TraumaRegister DGU®

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Zusammenfassung

Hintergrund

Explosionsverletzungen sind in Deutschland eine seltene Ursache schwerer Traumata und kaum Auslöser von Massenanfällen von Verletzten. Daher ist die Expertise in der Behandlung des individuellen explosionsverletzten Patienten eher als gering einzuschätzen.

Material und Methoden

Es erfolgte die manuelle retrospektive Identifikation aller Patienten des TraumaRegister DGU® (TR-DGU) der Jahre 1993–2011. Die deskriptive Beschreibung des Patientenkollektivs wurde im Vergleich zu 3 Vergleichskollektiven vorgenommen. Berechnet wurden Mittelwert, Standardabweichung und 95 %-Konfidenzintervall für verschiedene demographische Daten und Parameter der prähospitalen und innerklinischen Versorgung. Eine Prognoseabschätzung wurde mittels RISC (Revised Injury Severity Classification) und RISC II durchgeführt (TR-DGU-Projekt-ID 2012–035).

Ergebnisse

Im TR-DGU konnten 137 Patienten nach Explosionstrauma identifiziert werden. Die zu 90 % männlichen Patienten werden häufig (43 %) mittels Lufttransport in ein Traumazentrum geflogen. Das Kollektiv schwerverletzter Patienten (Injury Severity Score (ISS) = 18,0; 52 % mit ISS ≥ 16) muss bei kreislaufstabilen Vitalwerten nie notfallmäßig, jedoch auffällig häufig dringlich (59 %), d. h. noch vor der Aufnahme auf die Intensivstation, operativ versorgt werden. Im Verletzungsmuster imponieren mit 27 % schwere Weichteiltraumata (Abbreviated Injury Scale (AIS) ≥ 3), bei denen es sich in 90 % um Verbrennungen handelt. Bei sehr geringer innerklinischer Frühletalität von 3 % ist der Intensivaufenthalt tendenziell länger als in den Vergleichsgruppen (5,5 Beatmungs-, 10,7 Intensivtage). Organversagen trat in 36 %, Multiorganversagen in 29 % und septische Verläufe in 14 % der Fälle auf. Mit 16 % werden überproportional viele Patienten innerhalb von 48 h weiterverlegt. Der RISC sowie sein Nachfolger, der RISC II, unterschätzen die Verletzungsschwere/Letalität tendenziell (10,2 vs. 6,8 % bzw. 10,7 vs. 7,5 %) ebenso wie der Trauma-associated-severe-hemorrhage(TASH)-Score die Wahrscheinlichkeit einer Transfusion von mehr als 10 Erythrozytenkonzentraten unterschätzt (5,0 vs. 12,5 %).

Schlussfolgerung

Die Arbeit generiert Hypothesen, die einer weiteren konfirmatorischen Prüfung unterzogen werden sollten. Bis dahin muss aufgrund der gewonnenen Ergebnisse festgehalten werden, dass Patienten, die durch eine akzidentielle Explosion – nicht durch geplante (militärische/terroristische) Gewalt – verletzt werden, eine Kombination aus dem klassischen Schwerstverletzten mit zusätzlichem relevanten Anteil an schweren Verbrennungen aufweisen (thermomechanische Kombinationsverletzung). Ihr Intensivaufenthalt ist prolongiert und häufiger von relevanten Komplikationen gekennzeichnet, als dies bei anderen Traumapatienten der Fall ist. Scores, welche sich beim klassischen Schwerstverletzten bewährt haben (RISC/RISC II/TASH), unterschätzen dabei die Verletzungsschwere beim Explosionsverletzten tendenziell.

Abstract

Background

Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive.

Material and methods

A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012–035) was performed.

Results

A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %).

Conclusion

This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.

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Authors and Affiliations

  1. Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland

    M. Kulla DESA, J. Maier, L. Lampl & M. Helm

  2. Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs-, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland

    D. Bieler & S. Hentsch

  3. Institut für Forschung in der Operativen Medizin, Universität Witten-Herdecke, Witten, Deutschland

    R. Lefering

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  1. M. Kulla DESA
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R. Lefering ist Mitarbeiter des Instituts für Forschung in der Operativen Medizin an der Universität Witten-Herdecke. M. Kulla, D. Bieler, S. Hentsch und R. Lefering sind Mitglieder der Sektion NIS der DGU. J. Maier, L. Lampl und M. Helm geben an, dass kein Interessenkonflikt besteht.

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W. Mutschler, München

V. Braunstein, München

H. Polzer, München

Die Ergebnisse der Publikation beruhen u.a. auf Teilen der Auswertungen der Dissertation von Frau J. Maier an der Medizinischen Fakultät der Universität Ulm.

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Kulla, M., Maier, J., Bieler, D. et al. Zivile Explosionstraumata – ein unterschätztes Problem?. Unfallchirurg 119, 843–853 (2016). https://doi.org/10.1007/s00113-015-0046-3

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