Zusammenfassung
Hintergrund
Das Polytrauma ist die wichtigste Ursache für Morbidität und Mortalität in der Altersklasse bis 45 Jahre. Mit einem Anteil von 30–40 % ist die traumatische Hämorrhagie die häufigste vermeidbare Mortalitätsursache. Etwa jeder 4. polytraumatisierte Patient erleidet eine traumainduzierte Koagulopathie (TIC).
Material und Methoden
Es erfolgte eine selektive Literaturrecherche sowie Einbringung eigener Erfahrungen an einem überregionalen Traumazentrum zur Darstellung aktueller Erkenntnisse auf dem Gebiet des präklinischen Blutungs- und Volumenmanagements beim polytraumatisierten Patienten.
Ergebnisse
Der hämorrhagische Schock ist eine klinische Diagnose und die Erkennung durch den erstversorgenden Notarzt erfordert einen schnellen Überblick über Unfallhergang, Verletzungsmuster und hämodynamischen Status des Patienten. In Zukunft werden Hilfsmittel eine valide Einschätzung des Schockgeschehens erleichtern. Die Entstehung der TIC ist multifaktoriell und im Wesentlichen durch das Zusammenwirken von Gewebeschädigung, Schock, Hypothermie, Azidose und Verdünnung gekennzeichnet. Die präklinische Therapie orientiert sich am Konzept der „damage control resuscitation“ und umfasst die temporäre oder definitive Blutstillung, eine permissive Hypotension mit einem systolischen Zielblutdruck von 80–90 mmHg (≥ 80 mmHg bei SHT) durch zurückhaltende Infusion vornehmlich kristalloider Lösungen, den Wärmeerhalt und den Azidoseausgleich.
Schlussfolgerung
Der derzeitige Wissensstand und aktuelle Therapieempfehlungen sind dargestellt.
Abstract
Introduction
Polytrauma is the leading cause of morbidity and mortality in young adults (aged 35–45 years). At 30–40%, traumatic hemorrhage is the most frequent preventable cause of death. Approximately every fourth patient with multiple injuries suffers from trauma-induced coagulopathy.
Methods
The current knowledge of prehospital resuscitation of patients with multiple injuries based on a selective literature research and experience in a level I trauma center are presented.
Results
Hemorrhagic shock is a clinical diagnosis and the recognition by the first responding emergency physician requires rapid evaluation of the accident situation, injury pattern and patient’s hemodynamic status. In the future, tools will help to reliably estimate shock. Development of trauma-induced coagulopathy is multifactorial and is characterized by interaction of tissue damage, shock, hypothermia, acidosis and dilution. Preclinical therapy follows the concept of damage control resuscitation and involves bleeding hemostasis, permissive hypotension with a target systolic blood pressure between 80 and 90 mmHg (≥80 mmHg in presence of traumatic brain injury) by modest infusion of primarily crystalloid solutions, avoiding hypothermia and acidosis.
Conclusion
The current knowledge and therapy recommendations are presented.
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Interessenkonflikt. Marcel Winkelmann und Michaela Wilhelmi geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Winkelmann, M., Wilhelmi, M. Präklinisches Blutungs- und Volumenmanagement bei Schwerverletzten. Unfallchirurg 117, 99–104 (2014). https://doi.org/10.1007/s00113-013-2487-x
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DOI: https://doi.org/10.1007/s00113-013-2487-x
Schlüsselwörter
- Polytrauma
- Traumahämorrhagie
- „Damage control resuscitation“
- Hypotension, permissive
- Koagulopathie, traumainduzierte