Notfallmedizin up2date 2011; 6(4): e33-e64
DOI: 10.1055/s-0031-1280326
Spezielle Notfallmedizin
Georg Thieme Verlag KG Stuttgart · New York

Die S3-Leitlinie Polytrauma

Kernaussagen zu Thoraxtrauma, Schädel-Hirn-Trauma, Wirbelsäulenverletzungen und Extremitätenverletzungen
Steffen Ruchholtz
,
Hermann Bail
,
Mark Bardenheuer
,
Michael Bayeff-Filloff
,
Alexander Beck
,
Achim Biewener
,
Bertil Bouillon
,
Marc Fischbacher
,
Sebastian Hentsch
,
Ewald Hüls
,
Karl-Georg Kanz
,
Christian K. Lackner
,
Tobias Lindner
,
Ivan Marintschev
,
Gerrit Matthes
,
Hubert Mayer
,
Marcus Raum
,
Eckhard Rickels
,
Stefan Sauerland
,
Ulrich Schächinger
,
Michael Schädel-Höpfner
,
Th. Schildhauer
,
Karsten Schwerdtfeger
,
Andreas Seekamp
,
Erwin Stolpe
,
Johannes Sturm
,
Felix Walcher
,
Christian Waydhas
Further Information

Publication History

Publication Date:
12 December 2011 (online)

Kernaussagen

Thoraxtrauma

Eine klinische Untersuchung des Thorax und der Atemfunktion soll durchgeführt werden.

GoR A

Die Untersuchung sollte mindestens die Bestimmung der Atemfrequenz und die Auskultation der Lunge umfassen. Eine wiederholte Untersuchung sollte erfolgen.

GoR B

Die Inspektion (Seitendifferenz der Atemexkursion, Vorwölbung einer Seite, paradoxe Atmung), die Palpation (Schmerzen, Krepitationen, Hautemphysem, Instabilität) und die Perkussion (hypersonorer Klopfschall) des Thorax sowie die Pulsoxymetrie und, bei beatmeten Patienten, die Überwachung des Beatmungsdrucks können hilfreich sein.

GoR 0

Die Verdachtsdiagnose Pneumo- und/oder Hämatothorax soll bei einseitig abgeschwächtem oder fehlendem Atemgeräusch (nach Kontrolle der korrekten Tubuslage) gestellt werden. Das Fehlen eines solchen Auskultationsbefundes, insbesondere bei Normopnoe und thorakaler Schmerzfreiheit, schließt einen größeren Pneumothorax weitgehend aus.

GoR A

Die mögliche Progredienz eines kleinen, zunächst präklinisch nicht diagnostizierbaren Pneumothorax sollte in Betracht gezogen werden.

GoR B

Die Verdachtsdiagnose Spannungspneumothorax sollte gestellt werden bei einseitig fehlendem Atemgeräusch bei der Auskultation der Lunge (nach Kontrolle der korrekten Tubuslage) und dem zusätzlichen Vorliegen von typischen Symptomen, insbesondere einer schweren respiratorischen Störung oder einer oberen Einflussstauung in Kombination mit einer arteriellen Hypotension.

GoR B

Ein klinisch vermuteter Spannungspneumothorax soll umgehend dekomprimiert werden.

GoR A

Ein durch Auskultationsbefund diagnostizierter Pneumothorax sollte bei Patienten, die mit Überdruck beatmet werden, dekomprimiert werden.

GoR B

Ein durch Auskultationsbefund diagnostizierter Pneumothorax sollte bei nicht beatmeten Patienten in der Regel unter engmaschiger klinischer Kontrolle beobachtend behandelt werden.

GoR B

Die Entlastung eines Spannungspneumothorax sollte durch eine Nadeldekompression, gefolgt von einer chirurgischen Eröffnung des Pleuraspalts mit oder ohne Thoraxdrainage, erfolgen.

GoR B

Ein Pneumothorax sollte – sofern die Indikation besteht – durch eine Thoraxdrainage behandelt werden.

GoR B

Die Eröffnung des Pleuraraums sollte mittels Minithorakotomie erfolgen. Die Einlage der Thoraxdrainage sollte ohne Verwendung eines Trokars erfolgen.

GoR B

Schädel-Hirn-Trauma

Beim Erwachsenen sollte eine arterielle Normotension mit einem systolischen Blutdruck nicht unter 90 mmHg angestrebt werden.

GoR B

Ein Absinken der arteriellen Sauerstoffsättigung unter 90 % sollte vermieden werden.

GoR B

Die wiederholte Erfassung und Dokumentation von Bewusstseinsklarheit, Bewusstseinstrübung oder Bewusstlosigkeit mit Pupillenfunktion und Glasgow Coma Scale soll erfolgen.

GoR A

Auf die Gabe von Glukokortikoiden soll verzichtet werden.

GoR A

Bei Verdacht auf stark erhöhten intrakraniellen Druck, insbesondere bei Zeichen der transtentoriellen Herniation (Pupillenerweiterung, Strecksynergismen, Streckreaktion auf Schmerzreiz, progrediente Bewusstseinstrübung), können die folgenden Maßnahmen angewandt werden:

  • Hyperventilation

  • Mannitol

  • hypertone Kochsalzlösung

GoR 0

Bei perforierenden Verletzungen sollte der perforierende Gegenstand belassen werden, eventuell muss er abgetrennt werden.

GoR B

Wirbelsäulenverletzungen

Eine gezielte körperliche Untersuchung inklusive der Wirbelsäule und der mit ihr verbundenen Funktionen soll durchgeführt werden.

GoR A

Bei bewusstlosen Patienten soll bis zum Beweis des Gegenteils von dem Vorliegen einer Wirbelsäulenverletzung ausgegangen werden.

GoR A

Beim Fehlen folgender 5 Kriterien ist davon auszugehen, dass keine instabile Wirbelsäulenverletzung vorliegt:

  • Bewusstseinsstörung

  • neurologisches Defizit

  • Wirbelsäulenschmerzen oder Muskelhartspann

  • Intoxikation

  • Extremitätentrauma

GoR A

Akutschmerzen im Wirbelsäulenbereich nach Trauma sollten als ein Hinweis auf eine Wirbelsäulenverletzung gewertet werden.

GoR B

Bei akuter Lebensbedrohung (zum Beispiel Feuer/Explosionsgefahr), die nur durch sofortige Rettung aus dem Gefahrenbereich beseitigt werden kann, soll auch bei Verdacht auf eine Wirbelsäulenverletzung die sofortige und unmittelbare Rettung aus dem Gefahrenbereich erfolgen, ggf. auch unter Vernachlässigung von Vorsichtsmaßnahmen für den Verletzten.

GoR A

Die Halswirbelsäule soll vor der eigentlichen technischen Rettung immobilisiert werden.

GoR A

Der Transport sollte möglichst schonend und unter Schmerzfreiheit erfolgen.

GoR B

Patienten mit neurologischen Ausfällen und vermuteter Wirbelsäulenverletzung sollten primär und mindestens in ein regionales Traumazentrum mit Wirbelsäulenchirurgie transportiert werden.

GoR B

Extremitätenverletzungen

Stark blutende Verletzungen der Extremitäten, welche die Vitalfunktion beeinträchtigen können, sollen mit Priorität versorgt werden.

GoR A

Die Versorgung von Verletzungen der Extremitäten soll weitere Schäden vermeiden und die Gesamtrettungszeit beim Vorliegen weiterer bedrohlicher Verletzungen nicht verzögern.

GoR A

Alle Extremitäten eines Verunfallten sollten präklinisch orientierend untersucht werden.

GoR B

Eine auch nur vermutlich verletzte Extremität sollte vor grober Bewegung/dem Transport des Patienten ruhiggestellt werden.

GoR B

Grob dislozierte Frakturen und Luxationen sollten, wenn möglich, und insbesondere bei begleitender Ischämie der betroffenen Extremität/langer Rettungszeit annähernd präklinisch reponiert werden.

GoR B

Jede offene Fraktur sollte von groben Verschmutzungen gereinigt und steril verbunden werden.

GoR B

Aktive Blutungen sollten gemäß einem Stufenschema behandelt werden:

  • manuelle Kompression/Druckverband

  • (Hochlagerung)

  • Tourniquet

GoR B

Indikationen für einen sofortigen Gebrauch des Tourniquets/der Blutsperre können sein:

  • lebensgefährliche Blutungen/Multiple Blutungsquellen an einer Extremität

  • keine Erreichbarkeit der eigentlichen Verletzung

  • mehrere Verletzte mit Blutungen

GoR 0

Das Amputat sollte grob gereinigt und in sterile, feuchte Kompressen gewickelt werden. Es sollte indirekt gekühlt transportiert werden.

GoR B

 
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