Der Patient mit Thoraxtrauma: anästhesiologisches Management

Zusammenfassung

In der anästhesiologischen Praxis ist das Thoraxtrauma eine große Herausforderung. Verletzungen von Atemwegen, Lunge, Zwerchfell, Herz und großen thorakalen Gefäßen sind die vorherrschenden Probleme. Art und Ausmaß des chirurgischen Eingriffs sowie Wirkungen von Anästhetika und mechanischer Ventilation auf die pulmonale und kardiale Funktion sind besonders zu beachten.

Abstract

In daily practice, management of patients with blunt thoracic trauma is challenging for the anesthetist. Injuries of airways, lungs, diaphragm, heart and large vessels are the main difficulties.
Respiratory and circulatory physiology in general is affected by general anesthesia, which may result in an increased number of perioperative complications. Therefore, anesthetic management of patients with thoracic trauma needs to address different clinical topics: management of difficult airways, intrinsic effects of anesthetics and mechanical ventilation on respiratory and cardiac function, the adequate replacement of blood loss as well as type and extent of the surgical intervention. Postoperatively, sufficient pain therapy avoids pulmonary complications and can improve outcome.
Therefore, a high degree of (patho-)physiological understanding and manual skills are required in this scenario. Interdisciplinary cooperation during diagnostic, treatment and in the perioperative course is a prerequisite for a successful management.
The present work describes the main characteristics of thoracic trauma and discusses important precautions and typical problems the anesthetist has to face in the clinical setting.

Kernaussagen

• Das stumpfe Trauma ist die häufigste Verletzung im Thoraxbereich (> 95%).

• Das Thoraxtrauma wird anhand der verletzten Strukturen in verschiedene Kategorien unterteilt.

• Hauptursachen perioperativer Morbidität und Mortalität sind Atemwegsobstruktionen, Atemstillstand und Blutungen.

• Atemwegsverletzungen müssen unmittelbar bei der initialen Präsentation der Patienten diagnostiziert werden.

• Bei jedem Thoraxtrauma muss ein Pneumothorax ausgeschlossen werden.

• Die Anlage einer Thoraxdrainage sollte großzügig präoperativ erfolgen.

• Die Anwendung spezifischer Anästhetika ist weniger bedeutsam als die Kenntnis der physiologischen und pharmakologischen Prinzipien bei polytraumatisierten Patienten.

• Die Haupttodesursache beim stumpfen Thoraxtrauma stellt der massive Blutverlust mit konsekutiver Organischämie dar.

• Eine suffiziente Schmerztherapie des Patienten verringert die Inzidenz von postoperativen, insbesondere respiratorischen Komplikationen.

Schlüsselwörter

stumpfes Thoraxtrauma - perforierende Thoraxverletzung - anästhesiologisches Management - präoperative Evaluation - Schmerztherapie

Key words

blunt thoracic trauma - penetrating thoracic injury - anesthetic management - preoperative evaluation - pain therapy

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