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• Traumatic vs Cardiac arrest
• Evidenz & Epidemiologie
• Aktuelle Leitlinien & Handlungsempfehlungen
• Meaningful Interventions
Traumatic arrest
Lecture of Gareth Grier (London’s Air Ambulance) @AGN Congress Graz 2016 [email protected]
SMACC Force Dublin 2016, Intro Video [email protected]
SMACC Force Dublin 2016, Intro Video SMACC Force Dublin 2016, Intro Video [email protected]
londonsairambulance.co.uk
Impact Brain Apnea
[1] Atkinson JL, Mayo Clin Proc. 2000 75(1) 37-47, Wilson et al., Resuscitation 2016 https://vimeo.com/152287249 “Impact Brain Apnea”, G.Davies [email protected]
https://vimeo.com/152287249 “Impact Brain Apnea”, G.Davies
Impact Brain Apnea
John Hinds, “More Cases From The Races” lecture @SMACC Chicago [email protected]
URSACHEN:
• Hypovolaemie
• Hypoxie
• Spannungspneumothorax
• Herzbeuteltamponade
Traumatic arrest
URSACHEN:
• Hypovolaemie
• Hypoxie
• Spannungspneumothorax
• Herzbeuteltamponade
• Mit dem Leben unvereinbare Verletzungen
• Schweres SHT
Traumatic arrest
Meaningful interventions
URSACHEN:
• Hypovolaemie Blutverlust reduzieren
• Hypoxie Atemweg/Intubation
• Spannungspneumothorax bilat. Thorakostomien
• Herzbeuteltamponade Notthorakotomie
• Schweres SHT
• Mit dem Leben unvereinbare Verletzungen
Berlin – Kleber et al. 20141 (440 Px):
• 48% Hypovolaemie
• 13% Spannungspneumothorax
• 13% Hypoxie
• 10% Pericardtamponade
Traumatic arrest - EVIDENCE
[1] Kleber et al., Resuscitation 2014, 85, 405-410
• 34% Sturz aus >3m
• 22% Ueberrolltrauma
• 23% penetrierendes Trauma
• 74% der TCA versterben praehosp. • Zeit zum Eintreffen des Rettungsd. !! • ((Zeit bis Eintreffen im KH))
• 79% ROSC praehosp., 29% ueberleben • Davon 27% guter Neurologie • Von 440 Patienten nur 1 VF!!!
Berlin – Kleber et al. 20141 (440 Px):
• 64% hatten Fehler im praeklinischen Management – 49% Thoraxentlastung praeklinisch notwendig: nur 13% durchgefuehrt
– Instabiles Becken: nur 5% wurden praeklinisch stabilisiert
– 6% hatten Herzbeuteltamponade: KEINER wurde entlastet (Nadel oder Thorakotomie)
15% der Verstorbenen waeren sicher oder potentiell vermeidbar gewesen
Traumatic arrest - EVIDENCE
[1] Kleber et al., Resuscitation 2014, 85, 405-410 [email protected]
G. Davies 2013, London’s Air Ambulance:
Traumatic arrest - EVIDENCE
[1] Kleber et al., Resuscitation 2014, 85, 405-410 [email protected]
ATACC – Anaesthesia Trauma &
Critical Care Manual 2014 - UK
• Keine Herzdruckmassage
• Focus auf Blutungsstillung, Spannungspneumothorax, Atemweg
• Dann Resuscitative Thoracotomy, v.a. bei penetrierendem Trauma
Traumatic arrest
“One thing that is very clear is that this it not ALS!”
Meaningful interventions
URSACHEN:
• Hypovolaemie Blutverlust reduzieren
• Hypoxie Atemweg/Intubation
• Spannungspneumothorax bilat. Thorakostomien
• Herzbeuteltamponade Notthorakotomie
• Schweres SHT
• Mit dem Leben unvereinbare Verletzungen
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
REBOA: Resuscitative Endovascular Balloon occlusion of the Aorta • Beckenblutungen • Instabiler Patient • Kreislauf vorhanden
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
REBOA: Resuscitative Endovascular Balloon occlusion of the Aorta • Zur Stabilisierung/Zeitgewinn
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
londonsairambulance.co.uk [email protected]
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
Stannard 2011 [email protected]
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
Prytime REBOA Catheter
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
Wollongong CGD
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
INTECH Advanced, Heidelberg. Courtesy by Prof. Popp
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
Wollongong CGD [email protected]
Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung
londonsairambulance.co.uk [email protected]
ERC Leitlinien 2015, “Cardiac arrest in special circumstances”
Meaningful Interventions Entlastung eines Spannungspneumothorax
NICE – National Institute for Health and Care Excellence – UK
Meaningful Interventions Entlastung eines Spannungspneumothorax
Needle vs finger thoracostomy:
• IV catheters do not reach in up to 65% of the cases Can.J.Surg. 2010 53(3) 184, Prehosp.Emerg.Care 2009, 13(1) 14, J. Trauma 2008 64(1) 111, J. Trauma 2008 65(4) 964,
Accid. Emerg. Med. 1994 6 426, Injury 1996 5 321,, Arch. Surg. 2012 147(9) 813
• Anterior approach is not where you think it is Emerg. Med. J. 2003 20 383 (ED DOCS)
Meaningful Interventions Entlastung eines Spannungspneumothorax
Emerg. Med. J. 2003 20 383 [email protected]
www.smacc.net.au/2013/01/chest-decompression/ [email protected]
www.smacc.net.au/2013/01/chest-decompression/ [email protected]
www.smacc.net.au/2013/01/chest-decompression/ [email protected]
www.smacc.net.au/2013/01/chest-decompression/ [email protected]
Needle vs finger thoracostomy:
• IV catheters do not reach in up to 65% of the cases Can.J.Surg. 2010 53(3) 184, Prehosp.Emerg.Care 2009, 13(1) 14, J. Trauma 2008 64(1) 111, J. Trauma 2008 65(4) 964,
Accid. Emerg. Med. 1994 6 426, Injury 1996 5 321,, Arch. Surg. 2012 147(9) 813
• Anterior approach is not where you think it is Emerg. Med. J. 2003 20 383 (ED DOCS)
• If needle then lateral approach ANZ J. Surg. 2004 74(6) 420
Meaningful Interventions Entlastung eines Spannungspneumothorax
www.smacc.net.au/2013/01/chest-decompression/ [email protected]
Roberts & Hedges, Procedures in Emergency Medicine [email protected]
resus.me [email protected]
ERC Leitlinien 2015, “Cardiac arrest in special circumstances”
Meaningful Interventions Entlastung einer Herzbeuteltamponade
2004, EMJ 22(1):22–24, Wise, Davies, et al., Emergency thoracotomy: ‘‘how to do it’’ 2009, Resuscitation, Nov;80(11):1270-4 Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system 2010, Injury. 2010 Jul;41(7):1008-12, Is pre-hospital thoracotomy necessary in the military environment? 2011, J Trauma. May;70(5):E75-8, Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results 2013 Crit Care. 2013; 17(Suppl 2): P281, Sherren, Reid, et al. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service 2013 World J Surg (2013) 37:1277–1285, Sims et al. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study 2014 AEM Volume 65, no. 3, Slessor and Hunter, To Be Blunt: Are We Wasting Our Time? Emergency Department Thoracotomy Following Blunt Trauma: A Systematic Review and Meta-Analysis 2014 Der Unfallchirurg 117:849–852, Puchwein et al., Erfolgreiche präklinische Thorakotomie bei einem 17-jährigen Mann 2014 Forrester et al., ATACC Trauma Course Manual 8th edition, anaesthesia trauma & critical care 2015 Injury, Injury, Int. J. Care Injured 46 (2015) 1738–1742, Puchwein et al, Clamshell thoracotomy and open heart massage-A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study 2015 World J Surg (2015) 39:1306–1311, Flaris et al., Clamshell Incision Versus Left Anterolateral Thoracotomy. Which One is Faster When Performing a Resuscitative Thoracotomy? The Tortoise and the Hare Revisited Usw…
2015 J trauma acute care surg 79(1):159–173, July 2015 Seamon et al
Das kann keiner
ueberleben!!!???
Davies G. and Lockey D. J. Trauma: Thirteen survivors of prehospital thoracotomy for penetrating trauma: “A prehospital physician-performed resuscitation procedure that can yield good results”
• 15 Jahre retrospektiv, 13 ueberlebten, 11 davon neurologisch intakt
• Alle hatten eine Herzbeuteltamponade
• 7 Thorakotomien von Notfallmedizinern, 6 von Anaesthesisten
Puchwein et al. 2014 Der Unfallchirurg: “Erfolgreiche praeklinische Thorakotomie bei einem 17-jaehrigen Mann”
Meaningful Interventions Resuscitative Thoracotomy
londonsairambulance.co.uk [email protected]
Meaningful Interventions Resuscitative Thoracotomy
SOP der London’s Air Ambulance: Prehospit. Notthorakotomie
Meaningful Interventions Resuscitative Thoracotomy
SOP des SYDNEY HEMS Prehospit. Notthorakotomie
Was braucht man dazu?
4-E Prinzip:
• Expertise
• Equipment
• Environment
• Elapsed Time
Meaningful Interventions Resuscitative Thoracotomy
Roberts & Hedges, Procedures in Emergency Medicine [email protected]
Was braucht man dazu?
4-E Prinzip:
• Expertise
• Equipment
• Environment
• Elapsed Time
Meaningful Interventions Resuscitative Thoracotomy
1. Immer eine “Clamshell”
2013 World J Surg (2013) 37:1277–1285, Sims et al., Bilateral Anterior Thoracotomy (Clamshell Incision), Is the Ideal Emergency Thoracotomy Incision:, An Anatomic Study
2013 World J Surg (2013) 37:1277–1285, Sims et al. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study
2013 World J Surg (2013) 37:1277–1285, Sims et al. [email protected]
INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp [email protected]
ATACC manual version 8 [email protected]
Youtube.com, “Thoracotomy”, umemergencymed [email protected]
forensicpathologyonline.com [email protected]
Youtube, Dr. Paul Coimbra [email protected]
Youtube, Dr. Paul Coimbra [email protected]
INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp [email protected]
INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp Roberts & Hedges, Procedures in Emergency Medicine [email protected]
Youtube, Dr. Paul Coimbra [email protected]
Wie lernt man das?
-”INTECH Advanced”, Universitaetsklinikum Heidelberg REBOA, ultraschallgestützte Pericardpunktion, Clamshell-Thorakotomie und Notfallnähte -SMACC conference, pre-conference workshop: cadaver lab (“social media and critical care”), www.smacc.net.au -PERT course (Pre-Hospital and Emergency Department Resuscitative Thoracotomy) Royal College of Surgeons, UK, https://www.rcseng.ac.uk/courses/course-search/resuscitative-thoracotomy
Zusammenfassung
Traumaarrest ist keineswegs aussichtslos
Wer ueberlebt hat haufig keinen neurol. Schaden
Umdenken: weg von “standard” ALS im Trauma-Arrest
Traumatic arrest
DANKE
Traumatic arrest
