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Notfallmedizin up2date 2020; 15(01): 59-74
DOI: 10.1055/a-0958-0649
Traumatologische und chirurgische Notfälle
Georg Thieme Verlag KG Stuttgart · New York

Das Schädel-Hirn-Trauma im Erwachsenenalter

Aktuelle präklinische Handlungsempfehlungen
Paul Hagebusch
,
Andreas Pingel
,
Frank Kandziora
,
Reinhard Hoffmann
,
Uwe Schweigkofler
Further Information

Publication History

Publication Date:
28 February 2020 (online)

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Das Schädel-Hirn-Trauma ist auch heute noch die häufigste Todesursache bei Erwachsenen unter 45 Jahren. Der präklinischen Akutversorgung dieser Patienten kommt eine wichtige Rolle zu. Dabei spielen die Sicherung des Atemwegs, die Aufrechterhaltung eines adäquaten Kreislaufs sowie der zeitnahe Transport in die richtige Zielklinik eine entscheidende Rolle.
Kernaussagen

  • Das SHT bleibt die häufigste Todesursache bei Erwachsenen unter 45 Jahren.

  • Eine konsequente, leitlinienkonforme präklinische Therapie verbessert das Behandlungsergebnis.

  • Die Atemwegssicherung und Kreislaufstabilisierung haben am Unfallort höchste Priorität.

  • Hämodynamisch relevante Kopfplatzwunden sollten versorgt und die Blutung gestillt werden.

  • Der GCS eignet sich zu Beurteilung des Schweregrades des SHTs und sollte sequenziell erhoben werden.

  • Der Patient profitiert von einem zeitnahen, schnellen Transport in ein geeignetes Traumazentrum.

  • Die Prähospitalzeit von 60 Minuten sollte eingehalten werden.

  • Der Luftrettung kommt bei der Versorgung von SHT-Patienten eine entscheidende Rolle zu.

Schlüsselwörter

präklinische Versorgung - Schädel-Hirn-Trauma - Management SHT - Leitlinien SHT
 

  • Literatur

  • 1 Freude G, Mauer UM, Gässler H. et al. Prähospitale Versorgung des Schädel-Hirn-Traumas. Notarzt 2017; 33: 300-309
    Article in Thieme ConnectGoogle Scholar
  • 2 Walter J, Zweckberger K. Traumatische Verletzungen des zentralen Nervensystems. Fortschr Neurol Psychiatr 2019; 87: 57-67
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Spaite DW, Bobrow BJ, Keim SM. et al. Association of statewide implementation of the prehospital traumatic brain injury treatment guidelines with patient survival following traumatic brain injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg 2019; 154: e191152
    CrossrefPubMedGoogle Scholar
  • 4 van Essen TA, den Boogert HF, Cnossen MC. et al. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir (Wien) 2019; 161: 435-449
    CrossrefPubMedGoogle Scholar
  • 5 Auner B, Jakob H, Marzi I. Das schwer verletzte Kind. Orthop Unfallchir up2date 2016; 11: 305-326
    Article in Thieme ConnectGoogle Scholar
  • 6 Statistisches Bundesamt. Diagnosedaten der Patienten und Patientinnen in Krankenhäusern (einschl. Sterbe- und Stundenfälle). 2018. Im Internet: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Publikationen/Downloads-Krankenhaeuser/tiefgegliederte-diagnosedaten-5231301177015.html Stand: 01.09.2019
    PubMedGoogle Scholar
  • 7 Maegele M, Lefering R, Sakowitz O. et al. The incidence and management of moderate to severe head injury. Dtsch Arztebl Int 2019; 116: 167-173
    CrossrefPubMedGoogle Scholar
  • 8 Leitgeb J, Mauritz W, Brazinova A. et al. Impact of concomitant injuries on outcomes after traumatic brain injury. Arch Orthop Trauma Surg 2013; 133: 659-668
    CrossrefPubMedGoogle Scholar
  • 9 Pingel A, Schweigkofler U, Kandziora F. et al. Management des Schädel-Hirn-Traumas beim Polytrauma – Diagnostik und Therapie. Orthop Unfallchir up2date 2010; 5: 1-22
    Google Scholar
  • 10 Marehbian J, Neurology E, Box PO. et al. Medical management of the severe TBI patient. Neurocrit Care 2017; 27: 430-446
    CrossrefPubMedGoogle Scholar
  • 11 Hassan A, Jokar TO, Rhee P. et al. More helmets fewer deaths: Motorcycle helmet legislation impacts traumatic brain injury-related mortality in young adults. Am Surg 2017; 83: 541-546
    Google Scholar
  • 12 Liebigt S, Renner C. Das Schädel-Hirn-Trauma. Klinische Spezifika und Einteilung. Notfallmed up2date 2015; 10: 241-257
    Article in Thieme ConnectGoogle Scholar
  • 13 Forslund MV, Perrin PB, Røe C. et al. Global outcome trajectories up to 10 years after moderate to severe traumatic brain injury. Front Neurol 2019; 10: 219
    CrossrefPubMedGoogle Scholar
  • 14 Cheerio GS. Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med 2011; 58: 427-430
    CrossrefPubMedGoogle Scholar
  • 15 Balestreri M, Czosnyka M, Chatfield DA. et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry 2004; 75: 161-162
    PubMedGoogle Scholar
  • 16 Badjatia N, Carney N, Crocco TJ. et al. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care 2008; 12 (Suppl. 01) S1-S52
    CrossrefPubMedGoogle Scholar
  • 17 Galgano M, Toshkezi G, Qiu X. et al. Traumatic brain injury: Current treatment strategies and future endeavors. Cell Transplant 2017; 26: 1118-1130
    CrossrefPubMedGoogle Scholar
  • 18 Chang R, Cardenas JC, Wade CE. et al. Advances in the understanding of trauma-induced coagulopathy. Blood 2016; 128: 1043-1049
    PubMedGoogle Scholar
  • 19 Herbert JP, Guillotte AR, Hammer RD. et al. Coagulopathy in the setting of mild traumatic brain injury: Truths and consequences. Brain Sci 2017; 7: pii:E92
    CrossrefPubMedGoogle Scholar
  • 20 Liu J, Tian HL. Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury. Chinese J Traumatol Engl Ed 2016; 19: 172-175
    Google Scholar
  • 21 Samuels JM, Moore EE, Silliman CC. et al. Severe traumatic brain injury is associated with a unique coagulopathy phenotype. J Trauma Acute Care Surg 2019; 86: 686-693
    CrossrefPubMedGoogle Scholar
  • 22 Zhang J, Zhang F, Dong JF. Coagulopathy induced by traumatic brain injury: systemic manifestation of a localized injury. Blood 2018; 131: 2001-2006
    CrossrefPubMedGoogle Scholar
  • 23 MacKman N. The role of tissue factor and factor VII a in hemostasis. Anesth Analg 2009; 108: 1447-1452
    CrossrefPubMedGoogle Scholar
  • 24 Chapman MP, Moore EE, Moore HB. et al. Overwhelming tPA release, not PAI-1 degradation, is responsible for hyperfibrinolysis in severely injured trauma patients. J Trauma Acute Care Surg 2016; 80: 16-25
    CrossrefPubMedGoogle Scholar
  • 25 Hasadsri L, Wang BH, Lee JV. et al. Omega-3 fatty acids as a putative treatment for traumatic brain injury. J Neurotrauma 2013; 30: 897-906
    CrossrefPubMedGoogle Scholar
  • 26 Narayan RK, Maas AI, Marshall LF. et al. Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery 2008; 62: 776-786
    CrossrefPubMedGoogle Scholar
  • 27 Wutzler S, Maegele M, Marzi I. et al. Association of preexisting medical conditions with in-hospital mortality in multiple-trauma patients. J Am Coll Surg 2009; 209: 75-81
    CrossrefPubMedGoogle Scholar
  • 28 Batchelor JS GA. A meta-analysis to determine the effect of anticoagulation on mortality in patients with blunt head trauma. Br J Neurosurg 2012; 26: 525-530
    CrossrefPubMedGoogle Scholar
  • 29 Prexl O, Bruckbauer M, Voelckel W. et al. The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old. Scand J Trauma Resusc Emerg Med 2018; 26: 20
    CrossrefPubMedGoogle Scholar
  • 30 Zeeshan M, Jehan F, OʼKeeffe T. et al. The novel oral anticoagulants (NOACs) have worse outcomes compared with warfarin in patients with intracranial hemorrhage after TBI. J Trauma Acute Care Surg 2018; 85: 915-920
    CrossrefPubMedGoogle Scholar
  • 31 Firsching AR, Rickels E, Mauer UM. et al. Leitlinie Schädel-Hirn-Trauma im Erwachsenenalter (2015). AWMF-Register Nr 008/001 S2e. Stand 2016. Im Internet: https://www.awmf.org/uploads/tx_szleitlinien/008-001l_S2e_Schaedelhirntrauma_SHT_Erwachsene_2016-06.pdf Stand: 13.01.2020
    PubMedGoogle Scholar
  • 32 Stocchetti N, Furlan A VF. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma 1996; 50: 764-767
    Google Scholar
  • 33 Zafar SN, Millham FH, Chang Y. et al. Presenting blood pressure in traumatic brain injury: a bimodal distribution of death. J Trauma 2011; 71: 1179-1184
    CrossrefPubMedGoogle Scholar
  • 34 Fuller G, Hasler RM, Mealing N. et al. The association between admission systolic blood pressure and mortality in significant traumatic brain injury: A multi-centre cohort study. Injury 2014; 45: 612-617
    CrossrefPubMedGoogle Scholar
  • 35 Huang JF, Tsai YC, Rau CS. et al. Systolic blood pressure lower than the heart rate indicates a poor outcome in patients with severe isolated traumatic brain injury: A cross-sectional study. Int J Surg 2019; 61: 48-52
    CrossrefPubMedGoogle Scholar
  • 36 Spaite DW, Hu C, Bobrow BJ. et al. The impact of combined prehospital hypotension and hpoxia on mortality in major traumatic brain injury. Ann Emerg Med 2017; 69: 62-72
    CrossrefPubMedGoogle Scholar
  • 37 Krishnamoorthy V, Chaikittisilpa N, Kiatchai T. et al. Hypertension after severe traumatic brain injury: friend or foe?. J Neurosurg Anesthesiol 2017; 29: 382-387
    CrossrefPubMedGoogle Scholar
  • 38 Fujii T, Faul M, Sasser S. Risk factors for cervical spine injury among patients with traumatic brain injury. J Emerg Trauma Shock 2013; 6: 252-258
    CrossrefPubMedGoogle Scholar
  • 39 Meena US, Gupta A, Sinha VD. Prehospital care in traumatic brain injury: factors affecting patientʼs outcome. Asian J Neurosurg 2018; 13: 636-639
    PubMedGoogle Scholar
  • 40 Bossers SM, Schwarte LA, Loer SA. et al. Experience in prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: A systematic review and meta-analysis. PLoS One 2015; 10: e0141034
    CrossrefPubMedGoogle Scholar
  • 41 Rubenson Wahlin R, Nelson DW, Bellander BM. et al. Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort. Front Neurol 2018; 9: 194
    CrossrefPubMedGoogle Scholar
  • 42 Pakkanen T, Kämäräinen A, Huhtala H. et al. Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury. Scand J Trauma Resusc Emerg Med 2017; 25: 1-7
    CrossrefPubMedGoogle Scholar
  • 43 Gavrilovski M, El-Zanfaly M. Lyon RM. Isolated traumatic brain injury results in significant pre-hospital derangement of cardiovascular physiology. Injury 2018; 49: 1675-1679
    CrossrefPubMedGoogle Scholar
  • 44 Hylands M, Godbout MP, Mayer SK. et al. Vasopressor use following traumatic injury – A single center retrospective study. PLoS One 2017; 12: e0176587
    CrossrefPubMedGoogle Scholar
  • 45 Oddo M, Crippa IA, Mehta S. et al. Optimizing sedation in patients with acute brain injury. Crit Care 2016; 20: 128
    CrossrefPubMedGoogle Scholar
  • 46 Roberts DJ, Hall RI, Kramer AH. et al. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med 2011; 39: 2743-2751
    CrossrefPubMedGoogle Scholar
  • 47 Gu JW, Yang T, Kuang YQ. et al. Comparison of the safety and efficacy of propofol with midazolam for sedation of patients with severe traumatic brain injury: a meta-analysis. J Crit Care 2014; 29: 287-290
    CrossrefPubMedGoogle Scholar
  • 48 Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with neurological injury?. Anesth Analg 2005; 101: 524-534
    CrossrefPubMedGoogle Scholar
  • 49 Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol 2011; 10: 922-930
    CrossrefPubMedGoogle Scholar
  • 50 Brain Trauma Foundation; American Association of Neurological Surgeons, Congress of Neurological Surgeons. et al. Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma 2007; 24 (Suppl. 01) S71-S76
    CrossrefPubMedGoogle Scholar
  • 51 Bendinelli C, Ku D, Nebauer S. et al. A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury. ANZ J Surg 2018; 88: 455-459
    CrossrefPubMedGoogle Scholar
  • 52 Gäßler M, Ruppert M, Lefering R. et al. Pre-hospital emergent intubation in trauma patients: The influence of etomidate on mortality, morbidity and healthcare resource utilization. Scand J Trauma Resusc Emerg Med 2019; 27: 1-8
    CrossrefPubMedGoogle Scholar
  • 53 Wafaisade A, Caspers M, Bouillon B. et al. Changes in anaesthetic use for trauma patients in German HEMS – a retrospective study over a ten-year period. Scand J Trauma Resusc Emerg Med 2019; 27: 23
    CrossrefPubMedGoogle Scholar
  • 54 Lewis SR, Evans DJ, Butler AR. et al. Hypothermia for traumatic brain injury. Cochrane Database Syst Rev 2017; (09) CD001048 DOI: 10.1002/14651858.CD001048.pub5.
    CrossrefPubMedGoogle Scholar
  • 55 Davis DP, Dunford JV, Poste JC. et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma 2004; 57: 1-8
    CrossrefPubMedGoogle Scholar
  • 56 PHTLS® Deutschland. Stellungnahme zum Themenkomplex „Immobilisation von Traumapatienten“ durch das Nationale Board von PHTLS® Deutschland (Stand: März 2015). Im Internet: http://www.phtls.de/files/cto_layout/phtls/img/Stellungnahme_Immobilisation-PHTLS®_Deutschland_03-2015.pdf Stand: 05.12.2019
    PubMedGoogle Scholar
  • 57 Maissan IM, Ketelaars R, Vlottes B. et al. Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. Eur J Emerg Med 2018; 25: 24-28
    CrossrefPubMedGoogle Scholar
  • 58 Núñez-Patiño RA, Rubiano AM, Godoy DA. Impact of cervical collars on intracranial pressure values in traumatic brain injury: a systematic review and meta-analysis of prospective studies. Neurocrit Care 2019; DOI: 10.1007/s12028-019-00760-1.
    CrossrefPubMedGoogle Scholar
  • 59 Tan PG, Cincotta M, Clavisi O. et al. Review article: Prehospital fluid management in traumatic brain injury. Emerg Med Australas 2011; 23: 665-676
    CrossrefPubMedGoogle Scholar
  • 60 Turner J, Nicholl J, Webber L. et al. A randomised controlled trial of prehospital intravenous fluid replacement therapy in serious trauma. Heal Technol Assess 2000; 4: 1-57
    Google Scholar
  • 61 Cooper DJ, Myles PS, McDermott FT. et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004; 291: 1350-1357
    CrossrefPubMedGoogle Scholar
  • 62 Chowdhury T, Kowalski S, Arabi Y DH. Pre-hospital and initial management of head injury patients: An update. Saudi J Anaesth 2014; 8: 114-120
    CrossrefPubMedGoogle Scholar
  • 63 Hussmann B, Heuer M, Lefering R. et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 2015: 354-367
    Google Scholar
  • 64 Carney N, Totten AM, OʼReilly C. et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80: 6-15
    CrossrefPubMedGoogle Scholar
  • 65 CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifi cant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 107: 1994 doi:10.1016/S0140-6736(10)60835-5
    CrossrefPubMedGoogle Scholar
  • 66 The PATCH Study. Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH). Im Internet: https://clinicaltrials.gov/ct2/show/NCT02187120 Stand: 05.12.2019
    PubMedGoogle Scholar
  • 67 Zehtabchi S, Abdel Baki SG, Falzon L. et al. Tranexamic acid for traumatic brain injury: a systematic review and meta-analysis. Am J Emerg Med 2014; 32: 1503-1509
    CrossrefPubMedGoogle Scholar
  • 68 Armstead WM, Riley J, Vavilala MS. Norepinephrine protects cerebral autoregulation and reduces hippocampal necrosis after traumatic brain injury via blockade of ERK MAPK and IL-6 in juvenile pigs. J Neurotrauma 2016; 33: 1761-1767
    CrossrefPubMedGoogle Scholar
  • 69 Friess SH, Bruins B, Kilbaugh TJ. et al. Differing effects when using phenylephrine and norepinephrine to augment cerebral blood flow after traumatic brain injury in the immature brain. J Neurotrauma 2015; 32: 237-243
    CrossrefPubMedGoogle Scholar
  • 70 Pélieu I, Kull C, Walder B. Prehospital and emergency care in adult patients with acute traumatic brain injury. Med Sci (Basel) 2019; 7: pii:E12
    Google Scholar
  • 71 Lewis SR, Evans DJ, Butler AR. et al. Hypothermia for traumatic brain injury. Cochrane Database Syst Rev 2017; (09) CD001048
    PubMedGoogle Scholar
  • 72 Prabhakaran K, Petrone P, Lombardo G. et al. Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers. J Surg Res 2017; 219: 66-71 doi:10.1016/j.jss.2017.05.103
    CrossrefPubMedGoogle Scholar
  • 73 Deutsche Gesellschaft für Unfallchirurgie – DGU. Weißbuch Schwerverletztenversorgung. 3. Aufl.. Orthopädie und Unfallchirurgie; 2012. Im Internet: https://www.dgu-online.de/qualitaet-sicherheit/schwerverletzte/weissbuch-schwerverletztenversorgung.html Stand: 05.12.2019
    Google Scholar
  • 74 Naujoks F, Hagebusch P, Faul P. et al. Auswahl der richtigen Zielklinik – Welcher Patient in welche Klinik?. Notfallmed up2date 2019; 14: 47-66
    Article in Thieme ConnectGoogle Scholar
  • 75 Reimertz C, Ruppert M, Birner B. et al. Luftrettung – Ausblick und Perspektiven. Notfallmed up2date 2015; 10: 285-296
    Article in Thieme ConnectGoogle Scholar
  • 76 Schweigkofler U, Reimertz C, Lefering R. Importance of air ambulances for the care of the severely injured. Unfallchirurg 2015; 118: 240-244
    CrossrefPubMedGoogle Scholar
  • 77 Bouillon B, Pieper D. S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung AWMF Register-Nr. 012/019. 2016; 424. Im Internet: https://www.awmf.org/uploads/tx_szleitlinien/012-019l_S3_Polytrauma_Schwerverletzten-Behandlung_2017-08.pdf Stand: 05.12.2019
    PubMedGoogle Scholar
  • 78 Gross T, Schüepp M, Attenberger C. et al. Outcome in polytraumatized patients with and without brain injury. Acta Anaesthesiol Scand 2012; 56: 1163-1174
    Google Scholar
  • 79 McMillan TM, Teasdale GM. Death rate is increased for at least 7 years after head injury: A prospective study. Brain 2007; 130: 2520-2527
    CrossrefPubMedGoogle Scholar