Diagnostik und invasive Maßnahmen beim Thoraxtrauma

Zusammenfassung

Das Thoraxtrauma ist ein komplexes Verletzungsmuster, dessen Diagnostik und Therapie einem Notfallteam alles abverlangen. Der Begriff beschreibt Verletzungen des Brustkorbs in allen Facetten – von der Prellmarke eines Sicherheitsgurtes bis zum tödlichen Überrolltrauma mit Quetschung oder Zerreißung der Thoraxorgane. Bei der Therapie können sonografische Diagnostik und invasive Notfalltechniken erforderlich werden, die dieser Beitrag darstellt.

Abstract

Chest Trauma is a complex injury pattern whose diagnostics and therapy demand everything from an emergency response team. Chest trauma subsumes thoracic injuries in all facets from the bounce mark of a seat belt to fatal rollover trauma with contusion or disruption of organs located in the thorax. Possible causes comprise blunt or penetrating trauma, as well as decelerations, chemical and thermal damage. Sonographic assessment according to a protocol plays a major role in diagnosis of underlying conditions and treatment indications. Therapeutic management may include invasive emergency techniques: Decompression of a tension pneumothorax is a fundamental life-saving intervention. Pericardiocentesis seldomly is necessary or possible in order to drain a cardiac tamponade. In case of traumatic cardiac arrest and under defined circumstances, resuscitative thoracotomy may be indicated. The out-of-hospital management may require transfusion of blood components. As with all procedures, which are performed seldomly but under emergency conditions, invasive techniques require clear communication, precise structured working procedures and especially continuous training, team briefing, and debriefing.

Kernaussagen

• Das Thoraxtrauma kann eine Durchführung lebensrettender invasiver Techniken erfordern.

• Die Sonografie spielt eine entscheidende Rolle bei der Diagnostik und Indikationsstellung vor der Durchführung invasiver Maßnahmen.

• Die Entlastung eines Spannungspneumothorax ist eine lebensrettende Basisintervention.

• Eine Perikardpunktion ist selten erforderlich bzw. möglich, um eine Herzbeuteltamponade zu entlasten.

• Beim traumatischen Kreislaufstillstand ist unter bestimmten Bedingungen („4E“) eine Clamshell-Thorakotomie indiziert.

• Techniken, die selten und unter Notfallbedingungen durchgeführt werden, erfordern neben klarer Kommunikation und strukturierten Abläufen insbesondere regelmäßiges Training, Team-Briefing und Debriefing.

Schlüsselwörter

Thoraxtrauma - invasive Notfalltechniken - Notfallmedizin - Sonografie

Key words

thoracic injuries - invasive emergency procedures - emergency medicine - ultrasonography

Publication History

Article published online:
14 October 2020

• Literatur

• 1 Schneider N, Küßner T, Weilbacher F. et al. Invasive Notfalltechniken – INTECH Advanced. Notfall Rettungsmed 2019; 22: 87-99 doi:10.1007/s10049-018-0475-y
• 2 Zink W, Volkl A, Martin E. et al. [Invasive emergency techniques (INTECH). A training concept in emergency medicine]. Anaesthesist 2002; 51: 853-862 doi:10.1007/s00101-002-0385-7
• 3 Volpicelli G, Elbarbary M, Blaivas M. et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577-591 doi:10.1007/s00134-012-2513-4
• 4 Kirkpatrick AW, Sirois M, Laupland KB. et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 2004; 57: 288-295 doi:10.1097/01.ta.0000133565.88871.e4
• 5 Alrajab S, Youssef AM, Akkus NI. et al. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 2013; 17: R208 doi:10.1186/cc13016
• 6 Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995; 108: 1345-1348 doi:10.1378/chest.108.5.1345
• 7 Lichtenstein D, Meziere G, Biderman P. et al. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000; 26: 1434-1440 doi:10.1007/s001340000627
• 8 Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37: 224-232 doi:10.1007/s00134-010-2079-y
• 9 Lichtenstein DA, Lascols N, Prin S. et al. The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 2003; 29: 2187-2192 doi:10.1007/s00134-003-1930-9
• 10 Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J 2013; 34: 1186-1197 doi:10.1093/eurheartj/ehs372
• 11 AWMF. S3-Leitlinie: Polytrauma/Schwerverletzten-Behandlung. AWMF Register-Nr. 012/019. 07/2016. Im Internet (Stand: 27.07.2020): http://www.awmf.org/leitlinien/detail/ll/012-019.html
• 12 Kleber C, Giesecke MT, Tsokos M. et al. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 2013; 37: 1154-1161 doi:10.1007/s00268-013-1964-2
• 13 Deakin CD, Davies G, Wilson A. Simple thoracostomy avoids chest drain insertion in prehospital trauma. J Trauma 1995; 39: 373-374 doi:10.1097/00005373-199508000-00031
• 14 Truhlar A, Deakin CD, Soar J. et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95: 148-201 doi:10.1016/j.resuscitation.2015.07.017
• 15 Escott MEA, Gleiserg GR, Kimmel K. et al. Simple thoracostomy. Moving beyong needle decompression in traumatic cardiac arrest. JEMS 2014; 39: 26-32
• 16 McNamara JJ, Messersmith JK, Dunn RA. et al. Thoracic injuries in combat casualties in Vietnam. Ann Thorac Surg 1970; 10: 389-401 doi:10.1016/s0003-4975(10)65367-2
• 17 Adler Y, Charron P, Imazio M. et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC) Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36: 2921-2964 doi:10.1093/eurheartj/ehv318
• 18 Mekontso Dessap A, Chew MS. Cardiac tamponade. Intensive Care Med 2018; 44: 936-939 doi:10.1007/s00134-018-5191-z
• 19 Davey S, Alam F, Malik S. A delayed presentation of cardiac tamponade after blunt trauma. J Surg Case Rep 2011; 2011: 1 doi:10.1093/jscr/2011.9.1
• 20 Butler KL, Best IM, Weaver WL. et al. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma 2003; 54: 610-611 doi:10.1097/01.TA.0000046380.92001.81
• 21 Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med 2019; 37: 321-326 doi:10.1016/j.ajem.2018.11.004
• 22 Gao JM, Gao YH, Wei GB. et al. Penetrating cardiac wounds: principles for surgical management. World J Surg 2004; 28: 1025-1029 doi:10.1007/s00268-004-7523-0
• 23 Manz E, Nofz L, Norman AN. et al. Incidence of clotted haemopericardium in traumatic cardiac arrest in 152 thoracotomy patients. Scand J Trauma Resusc Emerg Med 2014; 22 (Suppl. 01) P20 doi:10.1186/1757-7241-22-s1-p20
• 24 De Carlini CC, Maggiolini S. Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal of Cardiology Practice 2017; 15: Nr19 Im Internet (Stand: 27.07.2020): http://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects
• 25 Choo TL, Wong KY, Chen CK. et al. Successful drainage of a traumatic haemopericardium with pericardiocentesis through an intercostal approach. Emerg Med Australas 2010; 22: 565-567 doi:10.1111/j.1742-6723.2010.01356.x
• 26 Petri N, Ertel B, Gassenmaier T. et al. “Blind” pericardiocentesis: A comparison of different puncture directions. Catheter Cardiovasc Interv 2018; 92: E327-E332 doi:10.1002/ccd.27601
• 27 Zerth H, Harwood R, Tommaso L. et al. An inexpensive, easily constructed, reusable task trainer for simulating ultrasound-guided pericardiocentesis. J Emerg Med 2012; 43: 1066-1069 doi:10.1016/j.jemermed.2011.05.066
• 28 Rudolph M, Lange T, Göring M. et al. Clamshell-Thorakotomie im Rettungsdienst und Schockraum: Indikationen, Anforderungen und Technik. Notarzt 2019; 35: 199-207 doi:10.1055/a-0869-7162
• 29 Flaris AN, Simms ER, Prat N. et al. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015; 39: 1306-1311 doi:10.1007/s00268-014-2924-1
• 30 Endo A, Shiraishi A, Otomo Y. et al. Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: analysis of a nationwide trauma registry. Crit Care 2017; 21: 169 doi:10.1186/s13054-017-1759-1
• 31 Obermaier M, Fiedler MO, Göring M. et al. Medical Intervention Car: Projekt zur Verbesserung der außerklinischen Notfallversorgung. Elsevier Emergency: Innovative Konzepte 2020; 3: 18-24