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Akute Maßnahmen beim „limb salvage“-Prozedere Teil 1

Blutungskontrolle, Notfallrevaskularisation, Kompartmentsyndromtherapie

Acute therapeutic measures for limb salvage Part 1

Haemorrhage control, emergency revascularization, compartment syndrome

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Zusammenfassung

Die Primärversorgung von Gustilo-Anderson-IIIC-Extremitätenverletzungen mit relevanten Gefäßverletzungen ist entscheidend für den Erfolg des „limb salvage“-Vorgehens. Vor dem Hintergrund der aktuellen Literatur stellt dieser Artikel die wesentlichen Notfallmaßnahmen für den Erhalt der nutritiven Perfusion der schwerstverletzten Extremität dar. Nach provisorischer Kontrolle der peripheren Blutung (z. B. durch manuelle Kompression oder Tourniquet) muss unmittelbar anschließend die Entscheidung über die Art der notfallmäßigen Revaskularisation als „limb salvage procedure“ fallen. Dabei ist der temporäre intravaskuläre Shunt die wichtigste perfusionserhaltende Technik bei Gefäßverletzungen. Bei der zeitlichen Abfolge von Frakturstabilisierung und Perfusionswiederherstellung hat die Verkürzung der Ischämiezeit die höhere Priorität.

Bei Verdacht auf ein akutes Kompartmentsyndrom muss in der „limb salvage“-Situation über 24 h hinweg ein dokumentiertes klinisches 4‑stündliches Monitoring erfolgen. Leitsymptome sind überproportionaler, analgetikaresistenter Schmerz und passiver Muskeldehnungsschmerz. Der positiv prädiktive Wert der klinischen Befunde ist <15 %. Während der Beobachtungsphase bei drohendem, aber noch nicht manifestem Kompartmentsyndrom ist eine Erhöhung der Extremität über Herzniveau und die Kühlung kontraindiziert. Die intrakompartimentelle Druckmessung stellt die wichtigste ergänzende apparative Untersuchungsmethode dar. Die offene operative Spaltung der betroffenen Kompartimente ist die einzige kausale Therapie und sollte so schnell wie möglich erfolgen. Die Entscheidung gegen eine Fasziotomie bei nicht eindeutiger Klinik sollte nicht ohne eine dokumentierte intrakompartimentelle Druckmessung erfolgen.

Abstract

The primary care of Gustilo-Anderson type IIIC extremity injuries with relevant vessel lacerations is decisive for the success of a limb salvage procedure. This article shall present substantial emergency procedures for the salvage of the nutritive perfusion of a mangled extremity, based on the current literature. After provisory control of a peripheral haemorrhage (e. g. by manual pressure or tourniquet), an immediate decision must be made about the kind of emergency revascularization to be implemented as the limb salvage procedure. Here, the temporary intravascular shunt will be the fastest technique that can ensure a sufficient tissue perfusion in the case of vessel lacerations. Regarding the treatment of a fracture versus perfusion recovery, a shortening of ischemia time should have priority over fracture stabilization.

If an acute compartment syndrome is suspected, a documented monitoring has to be performed in the limb salvage situation for 24 hours with clinical controls every 4 hours. Disproportional pain that does not respond to analgesics, and passive muscle stretching pain can be seen as cardinal symptoms. The positive predictive value of clinical findings is <15 %. During the observation period with an impending but not manifest compartment syndrome, an elevation of the extremity above heart level or its cooling are contraindicated. An intracompartmental pressure measurement is the most important instrument-based supplemental diagnostic method. The open fasciotomy of the affected compartments is the only causal therapy and should be performed as fast as possible. A decision against fasciotomy in cases of non-explicit clinical signs should not be made without a documented intracompartmental pressure measurement.

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C. Willy, M. Stichling, M. Engelhardt, D. Vogt und D.A. Back geben an, dass kein Interessenkonflikt besteht.

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Den Beitrag Akute Maßnahmen beim limb salvage“-Prozedere Teil 2 – Debridement, Lavagetechniken und antiinfektiöse Strategien finden Sie unter doi:10.1007/s00113-016-0178-0

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Willy, C., Stichling, M., Engelhardt, M. et al. Akute Maßnahmen beim „limb salvage“-Prozedere Teil 1. Unfallchirurg 119, 374–387 (2016). https://doi.org/10.1007/s00113-016-0179-z

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