Diagnostik und Behandlungskonzepte beim Thoraxtrauma

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.     

Anästhesiologische Probleme beim Thoraxtrauma

The paper describes respiratory problems after severe chest-injuries. After multiple rib-fractures the whole respiration can be affected, especially if sedatives have to be given. Special emphasis is laid upon supportive treatment in patients with pathological conditions of the lung. Furthermore the therapeutic procedure in cases of hematothorax, tension-pneumothorax, extensive subcutaneous emphysema and mediastinalemphysema are outlined. Common complications of these injuries are discussed.     

Videoassistierte thorakoskopische Chirurgie beim Thoraxtrauma

Video-assisted thoracoscopy (VATS) has a place in both diagnosis and treatment of blunt thoracic trauma. Thoracoscopy is indicated after trauma in the presence of intrathoracic hemorrhage, persisting pneumothorax, insufficiently drained hemothorax, chylothorax, and posttraumatic pleural empyema, and in some cases of diaphragmatic rupture and mediastinal injuries. The patient must be hemodynamically stable before VATS is performed, and it must also be possible to position the patient on one side and perform single-lung ventilation. It is absolutely mandatory to know what the contraindications to this procedure are and to take account of the general condition of the patient and the impact any other injuries might have. During the acute phase VATS allows surgical control of bleeding. In the case of lung injury a stapler can be used for resection, usually wedge resection. Evacuation of intrathoracic blood may prevent formation of pleural adhesions. For persistent pneumothorax pleurodesis is best performed by thoracoscopy. When VATS is performed after thoracic trauma there is a 2% complication rate, complications including transient hypoxemia, reversible cardiac arrhythmias, lung injury, bleeding in the chest wall, and intercostal neuralgia.     

Neue diagnostische Strategien beim Polytrauma

Zusammenfassung. Die diagnostische Strategie beim Polytrauma zielt auf schnellstm?gliche Erkennung von lebensbedrohlichen Verletzungen, Aufdeckung von relevanten organ- und funktionsgef?hrdenden L?sionen und Bilanzierung der systemischen Traumabelastung bzw. der daraus resultierenden Traumareaktionen. Neben strukturellen und organisatorischen Verbesserungen hat die hochentwickelte Bildgebung zu entscheidenden Fortschritten beigetragen. Ein systematisiertes Abkl?rungsprotokoll, integrierte Versorgung im interdisziplin?ren Team und eingespielte Algorithmen für h?ufige Leitsymptome sind die Schlüssel für ein erfolgreiches Schockraummanagement. Auf den aktuellen Stellenwert der g?ngigen diagnostischen Verfahren und ihren Einsatz beim K?rperh?hlentrauma wird besonders eingegangen.      

Strategien beim Endoprothesenwechsel der Schulter

The increasing number of primary shoulder arthroplasty operations is correlated to an increasing revision rate of up to 11.2?% for anatomical shoulder arthroplasty and 13.4?% for reverse shoulder arthroplasty. To reduce the risk of implant revision the surgeon has to take the possibility of late complications into account for the index operation and to choose a modular implant system. Indications for revision arthroplasty are secondary glenoid wear, aseptic loosening, infections, rotator cuff deficiency, instability, implant malpositioning, mechanical complications and periprosthetic fractures. Due to the high rate of humeral fractures during revision surgery of anatomical stemmed implants (12?%) and reverse implants (30?%) osteotomy of the humerus is of particular importance. Osteotomy of the humeral shaft with a distal window or transhumeral shaft osteotomy as described by Gohlke can be used. The most demanding step during implantation of the revision implant is the accurate reconstruction of the prosthetic height because the stability, strength of the deltoid muscle and in unfavourable situations the degree of stiffness in the glenohumeral joint all depend on the prosthetic height. The result of anatomical glenoid revision surgery totally depends on the bony defect. Revision glenoid components showed better results compared to glenoid reconstruction using a corticocancellous bone graft but resulted in a higher rate of secondary loosening of the glenoid implant. Cementless glenoid revision implants seem to achieve a higher stability of bony fixation than cemented implants. Due to a better form closure with the reverse humeral implant and a mechanically more favorable loading of the glenoid bone stock, the glenosphere should be implanted with an inferior tilt in revision surgery.     

Chirurgische Strategien beim Zufallsbefund eines Appendixkarzinoids

Carcinoids (neuroendocrine tumors NET) of the appendix are rare tumors and even today mostly detected only postoperatively by histopathology following operations for acute appendicitis or other abdominal procedures. Most NETs of the appendix are located at the tip of the appendix, less than 2?cm in size and non-metastasizing. Secondary right hemicolectomy with lymph node dissection bears a considerable risk of complications compared to simple appendectomy. To decide upon secondary surgery histopathological risk factors, such as grading, invasion of the mesoappendix, and tumor type in addition to tumor localization and size should be taken into consideration. Up to 20% of NETs of the appendix are associated with various neoplasms of the gastrointestinal tract. Follow-up examination should therefore also consider both appendix carcinoids and synchronous or metachronous neoplasms of the gastrointestinal tract.     

Hat die Thorakoskopie beim Thoraxtrauma einen Platz?

A hemodynamically stable patient presenting with persistent bleeding through his chest tube (ICD) is a classic indication for early thoracoscopic intervention in trauma. The source of bleeding and air leaks can be identified and often treated: bleeding and perforated pulmonary segments can be resected, and chest wall bleeding may be coagulated or sutured. Injuries to the diaphragm are difficult to diagnose, as they might not be seen in conventional trauma imaging without gross herniation of intra-abdominal contents into the thoracic cavity. Identifying the site of diaphragm perforation can give useful hints in thoracoabdominal trauma, identifying injured cavities and localizing the bullet or stab tract. Most often, diaphragmatic defects may be closed during diagnostic thoracoscopy as well. Non- or partially drainable hemothorax is another indication for thoracoscopy. Coagulated blood can be mechanically mobilised, and aspirated or primary bleeding may be stopped. Effective lavage and a high-performance suction device are required. Correct placement of the drainage is part of optimized therapy, along with inspection of all intrathoracic organs and surfaces. Furthermore, surgical and anaesthesiological teamwork and experience are prerequisites for the fast, professional application of a minimally invasive thoracoscopic approach in chest trauma patients. Diagnostically and theurapeutically, thoracoscopy plays an important role in the trauma setting--in the case of hemodynamically stable patients.     

Ultraschallgestützte thorakale Paravertebralblockade beim akuten Thoraxtrauma

Paravertebral blocks have experienced a renaissance because ultrasound-guidance is becoming common practice. The method is often presented as an alternative to thoracic epidural anaesthesia, mainly in the field of elective thoracic surgery. It is also propagated as an opioid-saving analgesic procedure in breast tumor surgery. In this case report it was successfully used as a continuous intervention for acute pain therapy of a severe injury of the left thorax. A transverse probe position in the fifth intercostal space was combined with an in-plane needle technique from lateral to medial. An ultrasound-enhanced needle positioning was used due to the steep angle of puncture. The absolute limit for medial needle advancement is the acoustic shadow of the transverse process. A catheter was placed 2 cm beyond the needle tip and its correct position was verified by hydrolocation. The excellent and continuous analgesia enabled non-invasive patient ventilation to be achieved directly after extubation and was continued for 6 days.     

Neue Strategien in der Volumenersatztherapie beim Polytrauma

Hemodynamic instability in polytraumatized patients is a predominant feature and most commonly secondary to blood loss accompanying injury. In these patients restoration of intravascular volume attempting to achieve normal systemic pressure faces the risk of increasing blood loss and thereby potentially affecting mortality.This review addresses one of today's key topics in preclinial trauma care, i.e.vigorous vs.moderate volume substitution therapy, and which kind of solutions seem to correspond best the needs of resuscitation of macrohemodynamics and shockinduced microcirculatory disturbances in particular.     

Die Wertigkeit der Ultraschalldiagnostik beim stumpfen Bauch- und Thoraxtrauma

Zusammenfassung In einer prospektiven Studie wurde der Ultraschall bei 103 Patienten mit stumpfem Bauch- und Thoraxtrauma als initiales bildgebendes Verfahren eingesetzt. Auf die Peritoneallavage wurde verzichtet. 22 Patienten (21%) hatten einen pathologischen Befund. Die Sensitivität betrug bei zwei falsch positiven Befunden 95,5%, die Spezifität bei einem falsch negativen Befund 97,5%. 14 Organverletzungen konnten im Ultraschall direkt nachgewiesen werden, bei den übrigen zeigte sich freie Flüssigkeit im Abdomen. Milz- und Leberverletzungen standen im Vordergrund, gefolgt vom Haematothorax. Die Ultraschalluntersuchung kann beim stumpfen Bauch-und Thoraxtrauma als initiales, bildgebendes Verfahren mit hoher Aussagekraft empfohlen werden.

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The use of ultrasonography in blunt abdominal and thoracic trauma

Summary In a prospective study, real-time ultrasonography was applied as the initial imaging procedure in 103 consecutive patients with blunt abdominal or thoracic trauma. Additional peritoneal lavage was not performed. Pathological findings were present in 22 patients (21%). Sensitivity of the examination was 95.5%, with two false positive results, specificity was 97.5% with one false negative result. Lesions of intraabdominal or thoracic organs were demonstrated directly by ultrasonography in 14 patients. In the remaining patients free fluid was discovered in the abdominal cavity. Splenic and hepatic lesions occurred most frequently followed by hematothorax. Ultrasonography can be recommended as the initial imaging procedure, giving a high amount of information in the primary diagnosis of blunt abdominal thoracic trauma.

     

Das Open Lung Concept Klinische Anwendung beim schweren Thoraxtrauma

INTRODUCTION: The pathomorphological substratum of the pulmonary contusion is a parenchymatous hemorrhage followed by interstitial and alveolar edema, finally resulting in a severe damage of the surfactant system. The pathophysiological consequence is an imbalance between ventilation and perfusion, which causes the clinical finding of hypoxia. METHODS: Between December 1997 and December 2000, we treated 32 polytraumatized patients (ISS 43, PTS 32) additionally suffering from severe chest contusion (AIS 5, PTST 14), by ventilation according to the Open Lung Concept (OLC). The initial disturbance of oxygenation was shown by a mean paO2/FIO2-ratio of 134 (96;181) mmHg. The OLC recruits atelectatic lung areas by the application of a defined temporary positive inspiratory pressure (PIP), which is called the "opening pressure". The recruited lung areas were kept open by high total-PEEP. RESULTS: For the recruitment procedure, a mean PIP of 65 (51;65) mbar was required. Recruited alveoli were kept open by a total-PEEP of 22 (20;23) mbar. The paO2/FIO2-ratio increased significantly (P < 0.001) from 134 (96;181) to 522 (433;587) mmHg. After the recruitment procedure, we could reduce PIP and FIO2. In spite of the minimal tidal volumes of 3.5 (3.0;3.9) ml per kg bodyweight by which our patients were ventilated, the levels of oxygenation and normocapnia could be maintained. There were no evidences for side-effects like perfusion impairment. Two patients (6.25%) died of extrapulmonary causes. CONCLUSION: Ventilation according to the OLC seems to be a highly effective treatment of ventilation-perfusion-impairment following pulmonary contusion. Minimal tidal volumes and the low PIP-levels after the recruitment procedure meet the demands of a lung-protective Low-Tidalvolume-Ventilation.     

Thoraxtrauma

Chest injuries can be sustained in isolation or in association with multiple injuries. Life-threatening complications may ensue because organs that are vital to survival of the organism are situated within the thoracic cavity. These complications include airway obstruction, tension pneumothorax, wide open pneumothorax, flail chest, cardiac tamponade and massive hemothorax. The mortality of patients hospitalized with chest injury can be as high as 10%. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential, and standard chest X-ray, ultrasound and thoracic computed tomography may also be needed for the diagnosis. The first part of this serial paper on the management of chest injuries focuses on anatomical aspects, pathophysiology and symptoms, but mainly on the indications for the standard diagnostic procedures and further high-tech examinations.     

Thoraxtrauma

Weiterbildungsinhalte für die Chirurgie, die unter dem speziellen Blickwinkel “Thoraxtrauma” von Relevanz sein k?nnen umfassen u. a. die Notfallr?ntgendiagnostik der Brusth?hle, die Durchführung der Regionalan?sthesie, die Durchführung der Schmerztherapie, Punktionen der Pleurah?hle, unkomplizierte Thorakotomien und Pleuradrainagen. Für den Schwerpunkt “Unfallchirurgie” sind neben zus?tzlicher Erfahrungen in der Sonographie und der R?ntgendiagnostik die Indikationsstellung zu und Befundung von CT, MRT und Angiogrammen und weitere Eingriffe an der Brustwand und Brusth?hle (z. B. Thorakotomien, Rippenresektionen, Thoraxdrainagen) gefordert. Im Rahmen der Behandlung von Polytraumatisierten hat die gute Kenntnis der Pathophysiologie, Diagnostik und Therapie des Thoraxtraumas einen hohen Stellenwert.     

Thoraxtrauma

Trauma und Berufskrankheit - In Westeuropa dominieren stumpfe Verletzungen des Thorax, penetrierende Verletzungen sind Raritäten. Entsprechend wenig Routine besteht in der Versorgung...     

Thoraxtrauma

Significant injuries to the thorax comprise pneumothorax, rib fractures, lung contusion, cardiac contusion, aortic laceration, ruptured diaphragm, and the very rare injuries to the tracheo-bronchial tree and the esophagus. A surgeon dealing with chest trauma patients needs to be familiar with the indications for and execution of chest tube insertion for thoracic drainage, pericardial puncture, and thoracoscopy and thoracotomy. Interventional techniques are gaining increasing acceptance in the management of major vascular injuries. The vast majority of patients with chest injury do not need an operative intervention, but it is necessary to place a thoracic drain in 10–15% of cases or to perform in a much lower proportion a pericardial puncture or a thoracotomy.