Zeitmanagement der operativen Therapie – was wird wann operiert?

Zusammenfassung

Die adäquate Versorgung eines polytraumatisierten Patienten ist nach wie vor eine individualisierte und anspruchsvolle Aufgabe. Die ersten Entscheidungen sollten nach dem Leitsatz: „Treat first, what kills first“ getroffen worden. An dieser Stelle gibt es wenig Raum für freie Entscheidungen. Schwierig wird es dann im Nachgang zu beurteilen, ab wann ein Patient für definitive Operationen von Frakturen operationsfähig ist. Hier wird immer mehr eine möglichst frühzeitige endgültige Versorgung angestrebt, um den Patienten schnellstmöglich mobilisieren zu können, das Risiko für Folgekomplikationen zu minimieren und generell die Intensivzeit zu verkürzen. Grundsätzlich gilt, stammnahe Frakturen werden zuerst versorgt (Wirbelsäule und Beckenring), danach die großen Röhrenknochen der Extremitäten (Oberarm/Oberschenkel) und anschließend dann die weiteren Frakturen. Die Behandlung der gleichzeitig bestehenden Weichteilverletzungen (offen > Kompartment > geschlossen) nehmen hier einen besonderen Stellenwert ein. Eine Sonderstellung nehmen Wirbelsäulenverletzungen mit und ohne Rückmarkläsionen ein. Neuere Studien belegen, dass das neurologische Outcome eines Patienten bei frühzeitiger (unter 24 Stunden, nach Möglichkeit sogar unter 8 Stunden) Versorgung signifikant besser ist, sofern eine Operabilität besteht.

Abstract

The adequate care of a polytraumatized patient is still an individualized and demanding task. The first decisions should be made according to the guiding principle: “Treat first, what kills first”. At this point, there is little room for free decisions. It then becomes difficult to assess later on when a patient is operational for definitive surgery of fractures. More and more people are looking for early care as soon as possible in order to mobilize the patient as quickly as possible, to minimize the risk of complications and to generally shorten the intensive care time. Basically, near-stem fractures are treated first (spine and pelvic ring), then the large bones of the extremities (upper arm/thigh) and then the other fractures. The treatment of concomitant soft tissue injuries (open > compartment > closed) occupy a special place here. Special emphasis is placed on spinal injuries with and without spinal cord lesions. Recent studies show that a patientʼs neurological outcome is significantly better with early (less than 24 hours, if possible even less than 8 hours) care, provided that there is an operability

Schlüsselwörter

Polytrauma - early care - Sekundärversorgung - Wirbelsäulenverletzungen - “treat first, what kills first”

Key words

polytrauma - early care - secondary care - spinal injuries - “treat first, what kills first”

• Literatur

• 1 Deutsche Gesellschaft für Unfallchirurgie. Hrsg. S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung. Im Internet: https://www.awmf.org/uploads/tx_szleitlinien/012-019l_S3_Polytrauma_Schwerverletzten-Behandlung_2017-08.pdf 29.11.2019
• 2 Klüter T, Lippross S, Oestern S. et al. [Operative treatment strategies for multiple trauma patients: early total care versus damage control]. Chirurg 2013; 84: 759-763 doi:10.1007/s00104-013-2478-z
• 3 Riska EB, von Bonsdorff H, Hakkinen S. et al. Primary operative fixation of long bone fractures in patients with multiple injuries. J Trauma 1977; 17: 111-121
• 4 Seibel R, LaDuca J, Hassett JM. et al. Blunt multiple trauma (ISS36), femur traction, and the pulmonary failure-septic state. Ann Surg 1985; 202: 283-295
• 5 Rotondo MF, Schwab CW, McGonigal MD. et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35: 375-382
• 6 Shapiro MB, Jenkins DH, Schwab CW. et al. Damage control: collective review. J Trauma 2000; 49: 969-978
• 7 Nicola R. Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRN Orthop 2013; 2013: 329452 doi:10.1155/2013/329452
• 8 Rostami E, Engquist H, Enblad P. Imaging of cerebral blood flow in patients with severe traumatic brain injury in the neurointensive care. Front Neurol 2014; 5: 114 doi:10.3389/fneur.2014.00114
• 9 Guo J, Yin Y, Jin L. et al. Acute compartment syndrome: cause, diagnosis, and new viewpoint. Medicine (Baltimore) 2019; 98: e16260 doi:10.1097/MD.0000000000016260
• 10 Waydhas C, Nast-Kolb D, Trupka A. et al. Posttraumatic inflammatory response, secondary operations, and late multiple organ failure. J Trauma 1996; 40: 624-631
• 11 Guerado E, Bertrand ML, Cano JR. et al. Damage control orthopaedics: state of the art. World J Orthop 2019; 10: 1-13 doi:10.5312/wjo.v10.i1.1
• 12 Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg 2012; 73: 1046-1063
• 13 Rixen D, Steinhausen E, Sauerland S. et al. members of the Damage Control Study Group. Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients. Trials 2016; 17: 47
• 14 Pape HC, van Griensven M, Rice J. et al. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: determination of the clinical relevance of biochemical markers. J Trauma 2001; 50: 989-1000
• 15 Cataneo AJ, Cataneo DC, de Oliveira FH. et al. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev 2015; (07) CD009919
• 16 Majeed FA, Zafar U, Imtiaz T. et al. Rib fixation versus conservative management of rib fractures in trauma patients. J Ayub Med Coll Abbottabad 2018; 30: 576-584
• 17 Olland A, Puyraveau M, Guinard S. et al. Surgical stabilization for multiple rib fractures: whom the benefit? -a prospective observational study. J Thorac Dis 2019; 11 (Suppl. 02) S130-S140
• 18 Fehlings MG, Vaccaro A, Wilson JR. et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS). PLoS One 2012; 7: e32037 doi:10.1371/journal.pone.0032037
• 19 Mattiassich G, Gollwitzer M, Gaderer F. et al. Functional outcomes in individuals undergoing very early (< 5 h) and early (5–24 h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurological improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma 2017; 34: 3362-3371 doi:10.1089/neu.2017.5132
• 20 Lee DY, Park YJ, Song SY. et al. The importance of early surgical decompression for acute traumatic spinal cord injury. Clin Orthop Surg 2018; 10: 448-454 doi:10.4055/cios.2018.10.4.448
• 21 Landi A, Marotta N, Ambrosone A. et al. Correlation between timing of surgery and outcome in thoracolumbar fractures: does early surgery influence neurological recovery and functional restoration? A multivariate analysis of results in our experience. Acta Neurochir Suppl 2017; 124: 231-238 doi:10.1007/978-3-319-39546-3_35
• 22 Du JP, Fan Y, Liu JJ. et al. Decompression for traumatic thoracic/thoracolumbar incomplete spinal cord injury: application of AO spine injury classification system to identify the timing of operation. World Neurosurg 2018; 116: e867-e873 doi:10.1016/j.wneu.2018.05.118
• 23 Verheyden AP, Spiegl UJ, Ekkerlein H. et al. Treatment of Fractures of the thoracolumbar spine: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8 (2 Suppl.): 34S-45S
• 24 Ter Wengel PV, Martin E, De Witt Hamer PC. et al. Impact of early (< 24 h) surgical decompression on neurological recovery in thoracic spinal cord injury: a meta-analysis. J Neurotrauma 2019; 36: 2609-2617 doi:10.1089/neu.2018.6277