S3-Leitlinie Polytrauma/Schwerverletztenversorgung

Kernaussagen

Intubationsindikationen, Präoxygenierung

Bei polytraumatisierten Patienten mit Apnoe oder Schnappatmung (Atemfrequenz < 6) sollen präklinisch eine Notfallnarkose, eine endotracheale Intubation und eine Beatmung durchgeführt werden.

GoR A

Bei polytraumatisierten Patienten sollten bei folgenden Indikationen präklinisch eine Notfallnarkose, eine endotracheale Intubation und eine Beatmung durchgeführt werden:

• Hypoxie (SpO₂ < 90 %) trotz Sauerstoffgabe und nach Ausschluss eines Spannungspneumothorax

• schweres Schädel-Hirn-Trauma (GCS < 9)

• traumaassoziierte hämodynamische Instabilität (RRsys < 90 mmHg)

• schweres Thoraxtrauma mit respiratorischer Insuffizienz (Atemfrequenz > 29)

GoR B

Der polytraumatisierte Patienten soll vor Narkoseeinleitung präoxygeniert werden.

GoR A

Die innerklinische endotracheale Intubation, Notfallnarkose und Beatmung sollen durch trainiertes und erfahrenes anästhesiologisches Personal durchgeführt werden.

GoR A

Training und Ausbildung

Notärztliches Personal soll regelmäßig in der Notfallnarkose, der endotrachealen Intubation und den alternativen Methoden zur Atemwegssicherung (Maskenbeatmung, supraglottische Atemwegshilfen, Notfallkoniotomie) trainiert werden.

GoR A

Alternative Methoden zur Atemwegssicherung

Bei der endotrachealen Intubation des Traumapatienten soll mit einem schwierigen Atemweg gerechnet werden.

GoR A

Bei der Narkoseeinleitung und endotrachealen Intubation des polytraumatisierten Patienten sollen alternative Methoden zur Atemwegssicherung vorgehalten werden.

GoR A

Innerklinisch soll bei der Narkoseeinleitung und endotrachealen Intubation eine Fiberoptik als Alternative verfügbar sein.

GoR A

Bei erwartet schwieriger Narkoseeinleitung und/oder endotrachealer Intubation soll innerklinisch ein anästhesiologischer Facharzt diese Verfahren durchführen bzw. supervisionieren, wenn dies keine Verzögerung einer sofort lebensrettenden Maßnahme bedingt. Es soll durch geeignete Maßnahmen sichergestellt werden, dass ein anästhesiologischer Facharzt im Regelfall rechtzeitig vor Ort ist.

GoR A

Nach mehr als 3 Intubationsversuchen sollen alternative Methoden zur Beatmung bzw. Atemwegssicherung in Betracht gezogen werden.

GoR A

Überwachung der Notfallnarkose

Zur Narkoseeinleitung, endotrachealen Intubation und Führung der Notfallnarkose soll der Patient mittels EKG, Blutdruckmessung, Pulsoxymetrie und Kapnografie überwacht werden.

GoR A

Notfallbeatmung und Kapnografie

Eine Kapnometrie/-grafie soll präklinisch bzw. innerklinisch im Rahmen der endotrachealen Intubation zur Tubuslagekontrolle und danach zur Dislokation- und Beatmungskontrolle angewendet werden.

GoR A

Beim endotracheal intubierten und narkotisierten Traumapatienten soll eine Normoventilation durchgeführt werden.

GoR A

Ab der Schockraumphase soll die Beatmung durch engmaschige arterielle Blutgasanalysen kontrolliert und gesteuert werden.

GoR A

Notfallnarkose

Bei polytraumatisierten Patienten soll zur endotrachealen Intubation eine Notfallnarkose aufgrund der meist fehlenden Nüchternheit und dem Aspirationsrisiko als „Rapid Sequence Induction“ durchgeführt werden.

GoR A

Etomidat als Einleitungshypnotikum sollte aufgrund der assoziierten Nebenwirkungen auf die Nebennierenfunktion vermieden werden (Ketamin stellt hier meistens eine gute Alternative dar).

GoR B

Endotracheale Intubation bei Verdacht auf HWS-Verletzung

Zur endotrachealen Intubation sollte die manuelle In-Line-Stabilisation unter temporärer Aufhebung der Immobilisation mittels HWS-Immobilisationsschiene durchgeführt werden.

GoR B

Kernaussagen

Volumentherapie bleibt ein kontroverses Thema. Nach Abwägung der Literatur und aller Expertenmeinungen der Konsensuskonferenzen kann man die folgenden Kernaussagen subsumieren:

• Bei schwer verletzten Patienten sollte eine Volumentherapie eingeleitet werden, die bei unkontrollierbaren Blutungen in reduzierter Form durchgeführt werden sollte.

• Bei hypotensiven Patienten mit einem Schädel-Hirn-Trauma sollte eine Volumentherapie mit dem Ziel der Normotension durchgeführt werden.

• Normotensive Patienten bedürfen keiner Volumentherapie, es sollten jedoch venöse Zugänge gelegt werden.

• Zur Volumentherapie bei Traumapatienten sollten Kristalloide eingesetzt werden.

• Isotone Kochsalzlösung sollte nicht verwendet werden, Ringer-Malat, alternativ Ringer-Acetat oder Ringer-Laktat, sollte bevorzugt werden.

• Werden bei hypotensiven Traumapatienten kolloidale Lösungen eingesetzt, sollte HAES 130/0,4 bevorzugt werden.

• Beim polytraumatisierten Patienten nach stumpfem Trauma mit hypotonen Kreislaufverhältnissen können hypertone Lösungen verwendet werden.

• Bei penetrierendem Trauma sollten hypertone Lösungen verwendet werden, sofern hier eine präklinische Volumentherapie durchgeführt wird.

• Bei hypotonen Patienten mit schwerem Schädel-Hirn-Trauma kann eine hypertone Lösung verwendet werden.

Michael Bernhard und Gerrit Matthes waren zu gleichen Teilen als Erstautoren an der Erstellung des Manuskripts beteiligt.

• Literatur

• Einführende Kästen

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• 2 Schmiegel W et al. S3-Leitlinie „Kolorektales Karzinom“. Available from:. http://www.krebsgesellschaft.de/download/s3_ll_kolorektales_karzinom_2008.pdf

• Atemwegsmanagement, Beatmung und Notfallnarkose

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• Volumentherapie

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