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”

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