Zusammenfassung
Das Schädel-Hirn-Trauma (SHT) ist zusammen mit dem hämorrhagischen Schock die führende Todesursache nach einem schweren Trauma. Die Letalität polytraumatisierter Patienten verdreifacht sich, wenn zusätzlich ein SHT vorliegt. Faktoren, die zu einem schlechten Outcome nach einem SHT beitragen wie Hypotension, Hypoxie, Hyperkapnie, Azidose, Koagulopathie und Hypothermie werden durch Ausmaß und Schwere der extrazerebralen Verletzungen weiter aggraviert. Wesentliche Eckpfeiler der SHT-Behandlung können zumindest temporär im Widerspruch zu den Therapiezielen der Polytraumabehandlung stehen. Zu nennen sind hier die Notwendigkeit normotensiver Blutdruckwerte trotz einer unkontrollierten Blutungssituation, die Aufrechterhaltung einer Normokapnie beim traumatischen Lungenversagen und die Thromboseprophylaxe. Da Unsicherheit hinsichtlich der Definition „normotensiver“ Blutdruckwerte besteht, ist eine CPP-gesteuerte (CPP = zerebraler Perfusionsdruck) Kreislauftherapie von zentraler Bedeutung. Unstrittig ist hingegen, dass ein unmittelbares, zielgerichtetes Gerinnungsmanagement das Outcome von SHT- und polytraumatisierten Patienten verbessert. Die Planung weiterführender Operationen muss an den Verlauf der SHT-Pathologie angepasst werden. Somit erfordert die Intensivtherapie des SHT beim Mehrfachverletzen eine enge Abstimmung mit den Traumatologen im Sinne eines individualisierten Behandlungskonzeptes.
Abstract
Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.
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H. Schöchl erhielt Referentenhonorare von CSL Behring TEM international, Baxter und AOP Orphan. H. Trimmel, G. Herzer, und W. G. Voelckel geben an, dass kein Interessenkonflikt besteht.
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Trimmel, H., Herzer, G., Schöchl, H. et al. Intensivtherapie des Schädel-Hirn-Traumas beim Mehrfachverletzten. Unfallchirurg 120, 739–744 (2017). https://doi.org/10.1007/s00113-017-0344-z
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DOI: https://doi.org/10.1007/s00113-017-0344-z