Interdisziplinäre Falldiskussion - bbraun.de · GCS B 8). However, missing a pelvic injury in the pre- However, missing a pelvic injury in the pre- hospital setting did not signL¿FDQWO\impact

$Page 1: Interdisziplinäre Falldiskussion - bbraun.de · GCS B 8). However, missing a pelvic injury in the pre- However, missing a pelvic injury in the pre- hospital setting did not signL¿FDQWO\impact$
Klinik für Unfall-, Hand- und Wiederherstellungschirurgie www.trauma.uni-frankfurt.de

Interdisziplinäre Falldiskussion

Behandlung aus Sicht des Unfallchirurgen

Prof. T. Lustenberger

Klinik für Unfall-, Hand- und Wiederherstellungschirurgie

Klinikum der JW Goethe-Universität, Frankfurt am Main

Direktor: Univ.-Prof. Dr. I. Marzi


• Als Bauarbeiter (m, 43J) von herabstürzender Verschalung (2m,

>20kg) am Kopf getroffen worden

• Stichwunde ca. 3cm re Oberbauch durch ca. 20cm langen

Gewindebolzen

• Von Arbeitskollegen auf Boden liegend vorgefunden, unfähig

aufzustehen

• Keine Bewusstlosigkeit

Unfallhergang

• RTW und NA vor Ort

Anlage Stiffneck

Verband Oberbauch rechts und Kopf

5L O2, Iono 500mL iv


Befund Schockraum externe Klinik

BGA: Hb 9.4, pH 7.2, BE -8.9, Lac 25

• GCS 14, Pupillen isokor, Hemiparese re KG 2-3/5, Sensibilität re

Körperhälfte eingeschränkt

• Kopfplatzwunde 10-15cm parietal rechts

• Thorax: stabil, Druckdolenz re, VAG

• Abdomen: ca. 2cm grosse Stichverletzung re Oberbauch, weich,

Druckdolenz re Oberbauch

• FAST: FF perihepatisch

• Becken stabil, Schmerzen re Leiste


Erstversorgung

• Maßnahmen

• Rö Thorax/Becken

• Beckenschlinge

• Intubation, ZVK, Arterie

Verlegung


Befund Schockraum

• Pupillen isokor, lichtreagibel

• Kopfplatzwunde parietal rechts

• Intubiert, VAG, Thorax: stabil

• Abdomen: ca. 2cm grosse Stichverletzung

re Oberbauch, weich,

• FAST: FF perihepatisch

• Becken: Beckengurt anliegend


Schockraum I

• Durchführung Trauma – Scan:

Offenes SHT

• SAB li parietal

• SDH li temporal, keine Mittellinienverlagerung

• Offene Mehrfragmentfraktur Os parietale li

• Hemiplegie rechts


Schockraum II


Thorax

• Lungenkontusionen bds

• Rippenserienfraktur rechts

Becken

• Vordere & hintere Beckenringfraktur


Schockraum III


Penetrierendes Abdominaltrauma

• Freie Flüssigkeit intraabdominell

• Leberlazeration Moor Grad IV


Unfallfolgen

Penetrierendes Abdominaltrauma• Leberlazeration Moor Grad IV

Offenes SHT• SAB li parietal



Hemiplegie rechts

Thorax• Lungenkontusionen bds


Becken• Vordere & hintere Beckenringfraktur

Wirbelsäule• LWK 2 Proc. Transversus Fraktur re

AIS

ISS 50

5

3

4

3

1


Vorgehen aus Sicht des Unfallchirurgen

Im Schockraum als Traumaleader

Anästhesie

Unfallchirurgie

Allgemeinchirurgie

Neurochirurgie

ZNA-Pflege

Radiologie

Innere Medizin

Urologie

MKG

Neurologie

Herz-

Thoraxchirurgie

Pädiatrie


Unfallchirurgie FA / OA 1

AA 1

Pflege 2

Anästhesie FA / OA 1

AA 1

Pflege 1

Radiologie FA 1

MTRA 1

Dokumentationsassistent, Intensivstation,

Labor, Blutbank, Transportdienst Konsiliarien Neurochirurige

Abdominalchirurgie

MKG

Thoraxchirurgie

OP Instr. Sr 1

Springer 1

Mitglieder des Schockraum-Teams


Penetrierend vs. stumpf

Zahlen TraumaRegister DGU

Jahresbericht 2014

Verletzungsmechanismus

Stumpfes Trauma 96.1%

Penetrierendes Trauma 3.9%

TraumaRegister DGU, Jahresbericht 2016


Vorgehen aus Sicht des Unfallchirurgen

Airway with cervical spine protection Atemweg,

Sicherung der HWS

Breathing and Ventilation Atmung, Thorax

Circulation-control external bleeding Circulation / Blutungskontrolle

Disability or neurological status Neurologie

Exposure and Environment Entkleiden/Wärmen

Im Schockraum als Traumaleader

ATLS


Anästhesie Chirurgie Radiologie

Atemweg

Ventilation

Carotispuls

Pupillen / GCS

SaO2 Sonographie Rö-Thorax

Blutdruck U-Thorax Rö-Becken

Herzfrequenz U-Becken

A

B

C

D

A/B

C

C

P r

i m

a r

yS

ur

v e

y

C

B

C

A/B/C

C

Paralleles Arbeiten im Schockraum


B/CKlinische Untersuchung Thorax


Therapeutische Maßnahmen

Thorax: Klinisch stabil, Druckdolenz re, VAG

Röntgen Thorax: kein PTX, kein HTX

Keine akute Maßnahme notwendig


Thorakotomie


Thorakotomie


Thorakotomie beim penetrierenden Trauma

Br J Surg. 2012 Apr;99(4):541-8.


Untersuchung Abdomen C


FAST

1

2 4

35

„Focussed Assessment with Sonography for Trauma“

Nachweis freier Flüssigkeit in einem der

präformierten Räume des Abdomens

eFAST (extended FAST)

Suche nach thorakalen, kardialen bzw.

perikardialen Verletzungen, die sich in einem

Pleuraerguss bzw. Perikarderguss manifestieren

• subkutanes Emphysem

• voroperierten Patienten mit intraperitonealen Verwachsungen und Adhäsionen

• ungenügende Beurteilbarkeit von Pankreas und Hohlorganverletzungen

• mangelhafte Beurteilbarkeit des retroperitonealen Raumes

Limitationen

C


Untersuchung Abdomen

Abdomen: ca. 2cm grosse Stichverletzung re Oberbauch, weich

FAST: freie Flüssigkeit perihepatisch

Cave: Zweihöhlenverletzung

Thorakoabdominale Region

Rechte / linke Pleuraraum

Mediastinum

Kraniale Peritonealhöhle

Oberes Retroperitoneum

C


Untersuchung Abdomen C

Ausschluss Zweihöhlenverletzung


CBeckenuntersuchung / Pelvic Sling

Bedeutung der korrekten Positionierung eines Beckengurts zur temporaren Stabilisierung

von Beckenringverletzungen.

Fleiter et al., Z Orthop Unfall 2012; 150: 627–629



Bedeutung der korrekten Positionierung eines Beckengurts zur temporaren Stabilisierung

von Beckenringverletzungen.

Fleiter et al., Z Orthop Unfall 2012; 150: 627–629


Table 5 delineates outcomes in the overall patient pop-

ulation. For all groups, the observed mortality rate was

lower than the predicted mortality (RISC). No statistically

significant difference in terms of mortality was found when

comparing missed and correctly suspected pelvic fractures.

Overall, 33.0 % of the patients were transfused until SICU

admission, with 9.7 % of the patients undergoing massive

transfusion. Similar results were found when analyzing

type C pelvic fractures only (Table 6).

Discussion

The existing body of published evidence indicates that with

a high level of suspicion and experience, a clinical

assessment is highly sensitive to rule out significant pelvic

injuries in the blunt trauma patient [1–8]. However, to the

best of our knowledge, the vast majority of these studies

were performed during the in-hospital resuscitation period;

the reliability of the out-of-hospital evaluation and physical

examination of the pelvis, performed by the emergency

physician at the scene, has not been addressed in the lit-

erature so far. The main finding of the present study is that

a significant proportion of severe pelvic fractures type B

and C (40.5 and 32.3 %, respectively) wasnot suspected by

the emergency physician at the scene. Risk factors

associated with missing a pelvic fracture mainly included

an altered level of consciousness (relevant head injury,

GCS B 8). However, missing a pelvic injury in the pre-

hospital setting did not significantly impact the in-hospital

outcome with regard to mortality and the requirement for

an early transfusion.

In the majority of studies, the overall sensitivity for

detecting a clinically relevant pelvic fracture requiring

specific treatment was close to 100 %. In the study by

Gonzalez et al., evaluating a total of 2176 consecutive

blunt trauma patients presenting with a GCS C 14, only 7

out of 97 pelvic fractures were missed on clinical exami-

nation; none of the missed fractures required surgical

intervention (sensitivity, 93 %) [5]. In a meta-analysis

assessing the reliabili ty of the clinical examination in

detecting pelvic fractures, and pooling a total of 12 studies

with 5454 patients, the overall sensitivity and specificity

were both found to be 0.9, equaling a false negative and

false positive rate of 10 %, respectively. Thus, the authors

concluded that in the stable and alert trauma patient, a

thorough clinical examination in the emergency depart-

ment detects pelvic fractures with a sensitivity of nearly

100 % [7]. Contrary to these findings, few other studies

reported lower sensitivities for clinically diagnosing pelvic

instabil ity, ranging from 27 to 59 % [12–14]. Our findings

add to these results with regard to the reliabili ty of the pre-

Table 2 Relationship between pre-hospital suspected and radiologically proven pelvic fracture according to the pelvic AIS score

Suspicion of ‘‘pelvic injury’’ by the emergency physician at the scene

No pelvic injury

n = 3178

Minor pelvic injury

n = 2186

Moderate pelvic injury

n = 2970

Severe pelvic injury

n = 2728

Severity of pelvic injury

AIS 0 (n = 3861) 0 % (0)a 44.8 % (1728) 35.9 % (1387) 19.3 % (746)

AIS 2 (n = 2358) 55.8 % (1316) 8.8 % (208) 21.2 % (500) 14.2 % (334)

AIS 3 (n = 1610) 45.0 % (725) 6.1 % (99) 24.9 % (401) 23.9 % (385)

AIS 4 (n = 2750) 36.1 % (992) 5.1 % (140) 22.1 % (609) 36.7 % (1009)

AIS 5 (n = 483) 30.0 % (145) 2.3 % (11) 15.1 % (73) 52.6 % (254)

a Per definition/inclusion criteria: included were patients with a proven pelvic fracture or suspicion of a pelvic injury only

Table 3 Relationship between pre-hospital suspected and radiologically proven pelvic fracture according to the Tile pelvic fracture type

classification

Suspicion of ‘‘pelvic injury’’ by the emergency physician at the scene

No pelvic injury

n = 3178

Minor pelvic injury

n = 458

Moderate pelvic injury

n = 1583

Severe pelvic injury

n = 1982

Pelvic fracture (radiologically proven)

Type A (n = 2737) 54.5 % (1491) 8.2 % (225) 21.6 % (592) 15.7 % (429)

Type B (n = 2986) 40.5 % (1209) 5.3 % (157) 22.3 % (665) 32.0 % (955)

Type C (n = 1478) 32.3 % (478) 5.1 % (76) 22.1 % (326) 40.5 % (598)

World J Surg

123

Author's personal copy

ORI GI NA L SCI ENTI FI C REPORT

The Reliability of the Pre-hospital Physical Examinationof the Pelvis: A Retrospective, Multicenter Study

Thomas Lustenberger 1• Felix Walcher 2

• Rolf Lefer ing3• Uwe Schweigkofler4

•

Hendr ik Wyen1• Ingo Marzi1 • Sebastian Wutzler1

• the TraumaRegister DGU

Ó Societe Internationale de Chirurgie 2016

Abstract

Introduction This study assesses the incidence of missed pelvic injuries in the pre-hospital setting.

Methods All blunt trauma patients (ISS C 9) with pre-hospital suspicion of and/or radiologically proven pelvic

fracture documented in the TraumaRegister DGUÒ (TR-DGU) of the German Trauma Society DGU (2002–2011)

were identified and retrospectively analyzed. Patients with a missed pelvic injury in the pre-hospital period were

compared with those who were correctly identified.

Results Of the 11,062 patients included, 7201 patients (65.1 %) had a pelvic fracture diagnosed on hospital

admission. In 44.1 % (n = 3178) of the patients with confirmed pelvic fracture, no pelvic injury was suspected pre-

clinical ly (overall sensitivity of the pre-hospital pelvic examination: 55.9 %). For type B and C pelvic fractures,

40.5 % and 32.3 %, respectively, were not suspected in the pre-hospital environment. Patients with a not-suspected

pelvic injury were significantly more likely to have been involved in a motor vehicle accident, to have a GCS B 8, to

be intubated at the scene and to have an ISS of C25 (all p \ 0.05). Independent risk factors for missing a pelvic

injury in the pre-hospital setting were an AIS head C3, a GCS B 8 and age above 60 years. The presence of

hypotension (SBP B 90 mmHg) as well as a high overall injury severity (ISS C 25) decreased the risk of missing a

pelvic injury.

Conclusion A significant proportion of severe pelvic fractures type B and C were not suspected in the pre-hospital

setting. Therefore, in severely injured blunt trauma patients, a mechanical pelvic stabilization in the pre-hospital

environment, irrespective of the findings of the physical examination of the pelvis, should be considered.

Introduction

The early detection of pelvic fractures plays an important

role in the initial management of multiply injured trauma

patients. The available data uniformly indicate that a

TraumaRegister DGU Committee on Emergency Medicine, Intensive

Care and Trauma Management of the German Trauma Society

(Sektion NIS), TraumaRegister DGU: www.traumaregister.de.

& Thomas Lustenberger

[email protected]

1 Department of Trauma, Hand and Reconstructive Surgery,

University Hospital Frankfurt, Goethe-University Frankfurt/

Main, Theodor Stern Kai 7, 60590 Frankfurt am Main,

Germany

2 Department of Trauma, University Hospital, Leipziger Str.

44, Magdeburg A.O.R., Germany

3 Institute for Research in Operative Medicine (IFOM),

University of Witten/Herdecke, Ostmerheimer Str. 200,

51109 Cologne, Germany

4 Department of Trauma und Orthopedic Surgery,

Berufsgenossenschaftliche Unfallklinik Frankfurt/Main,

Frankfurt am Main, Germany

123

World J Surg

DOI 10.1007/s00268-016-3647-2

Author's personal copy

Untersuchung Becken

„Nicht erkannte“ Beckenfrakturen

C

World J Surg. 2016 Jul 26.



Becken stabil, Schmerzen re Leiste

Pelvic Binder anliegend

Keine akute Maßnahme notwendig


Neurologie D

Pupillen isokor, initial Hemiparese re KG 2-3/5

initial Sensibilität re Körperhälfte eingeschränkt


Unfallfolgen

Penetrierendes Abdominaltrauma• Leberlazeration Moor Grad IV

Offenes SHT• SAB li parietal



Hemiplegie rechts

Thorax• Lungenkontusionen bds


Becken• Vordere & hintere Beckenringfraktur

Wirbelsäule• LWK 2 Proc. Transversus Fraktur re

AIS

ISS 50

5

3

4

3

1


Indikation für Damage Control Surgery

o ISS≥16 und /oder

o Schweres Schädel-Hirn-Trauma (AIS≥3)

o Schweres Thoraxtrauma (AIS≥3)

o Instabile Beckenfraktur

o Multiple Frakturen langer Röhrenknochen (Femur, Tibia,

Humerus)

o Persistierend instabiler Kreislauf (RR<90mmHg)

„Damage Control Orthopedics“ Nast-Kolb et al. (2005), Unfallchirurg 108:804-811


Phase 1

sofort

Blutstillung

Entlastung

Phase 2

Unfalltag

Stabilisierung

Debridement

Intermediär

ca. 2.- 5. Tag

Second Look

Intensivtherapie

Phase 3

ca. ab Tag 6

Verfahrenswechsel

Rekonstruktion

Ziele

Operative Strategie in der Klinischen Versorgung des Polytraumas

Marzi et al. Zentralblatt für Chirurgie 121: 950-962, 1996

Stufenkonzept der operativen Versorgung

Penetrierende Bauchverletzung

SHT


Stabilisierung und „Damage Control“:

• offene Frakturen

• Kompartmentsyndrome

• Frakturen langer Röhrenknochen

• Luxationen

• Darm- und Harnblasenverletzungen

• instabile Wirbelsäulenverletzungen

Phase 2: Dringliche Operationen


Phase 3

Osteosynthesewechsel

Osteosynthesekomplettierung

Rekonstruktive Maßnahmen

minimal-invasive Eingriffe

d38

- ISG Schraube

- Supraacetabulärer Fixateur

externe


ME Fixateur externe


Schockraummanagement

= interdisziplinäres Management

Traumaleader

Erkennen und Festlegen der Behandlungsprioritäten

Gemeinsame Sprache


[email protected]

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Interdisziplinäre Falldiskussion - bbraun.de · GCS B 8). However, missing a pelvic injury in the pre- However, missing a pelvic injury in the pre- hospital setting did not signL¿FDQWO\impact