Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie最新文献

After severe trauma, but also perioperatively, massive bleeding is associated with increased morbidity and mortality. In severely injured patients, hemorrhagic shock remains to be the main cause of death in addition to traumatic brain hemorrhage. In non-cardiac surgery, a surgical bleeding complication increases perioperative morbidity (intensive care length of stay, acute renal failure, infections, thromboembolic complications) by a factor of three to four and mortality by a factor of six. In cardiac surgery, postoperative bleeding requiring surgical revision is associated with a 50% increase in mortality. One possible therapeutic approach is the transfusion of erythrocytes to plasma in a fixed ratio. This practice of untargeted coagulation therapy is mainly used in the USA and some Scandinavian countries. Mortality is significantly worse in the USA than in central Europe, particularly in the case of severe injuries. There is increasing evidence that targeted coagulation therapy with coagulation factor concentrates based on the results of point-of-care coagulation diagnostics is more effective and associated with fewer transfusion- and bleeding-related complications.

The aim of red blood cell (RBC) transfusion is to prevent or treat anemic tissue hypoxia in acute or chronic anemia. In 2022, approximately 3.2 million red blood cell transfusions were conducted in Germany. Most blood products are transfused in surgical medicine. RBC units should be used appropriately, based on recent evidence about their indications, profound knowledge on handling, correct documentation as well as possible associated risks of transfusion-associated adverse events and their respective treatments. Blood loss in particular increases the risk of an imbalance between oxygen supply and oxygen demand. Targeted, rational (restrictive) blood transfusion based on physiological transfusion triggers makes it possible to avoid organ injury due to anemic hypoxia.

For two years now, anaesthesia technical assistance has been a state-recognized profession in Germany and entitles graduates to work in all fields of anaesthesiology, with the exception of the intensive care unit. The job profile is comparable to the nurse anesthetist in Great Britain (Operation Department Practitioner) or in the Netherlands (Anesthesiemedewerker). In an initial empirical research project in 2023, the professional field was described and the question of whether graduates are adequately prepared for the fields of anaesthesiology was discussed with the focus particularly on the recovery room. The normative requirements of the theoretical and practical training prepare the trainees well for all fields of the profession. However, the study showed that training should be improved by including practical work in the intensive care unit during schooling. The existing training and examination regulations currently only offer a small amount of scope for an assignment in the intensive care unit. Therefore, the training and in particular the practical assignments should be evaluated and modified in the future.

Transfusion of platelet concentrates (PC) can be a life-saving measure in case of severe thrombocytopenia or thrombocytopathy, particularly in bleeding patients. Although acaryote, platelets are involved in several important functions including immunomodulation, but their most important function is in primary and secondary haemostasis. In this German review, apheresis and whole blood derived PC are compared and indications as well as transfusion triggers and dosage of PC are discussed. Apart from emergencies, transfusion of PC can only occur after informed consent. Therefore, the treating physician should be aware of the potential adverse events and their prophylaxis in order to best advise the patient. Eight of the most prevalent and/or clinically severe adverse events following PC transfusion and their handling and prevention are discussed. In addition, practical aspects of PC transfusion are depicted as well as the treating physician's choice of the appropriate PC including a flowchart for refractory patients.

In Germany, blast and gunshot injuries are uncommon but complex injury entities. Due to the global political situation, terrorist attacks, accidents, or acts of violence, these injuries are potentially part of the reality of care for every anaesthetist, surgeon, and emergency physician. In principle, this type of injury should be treated in a trauma centre with appropriate expertise, but the knowledge of basic treatment principles is necessary for all practitioners. First, emergency training and surgical simulation courses should be carried out regularly to remain confident in emergency surgery techniques and treatment strategies. In addition, minimally invasive methods are predominantly used in elective surgery, meaning that the routine of primarily open surgery is missing. Therefore, it is important that surgeons learn surgical steps to be better prepared for emergency open surgery.The critical principle of damage control surgery is stopping the bleeding and the contamination and preventing a delay in intensive care therapy. For penetrating thoracic trauma, a chest tube must be inserted. If the patient is hemodynamically unstable, an anterolateral thoracotomy should be performed to achieve bleeding control, e.g., by cross-clamping the aorta or pulmonary hilum. For stable patients, a video-assisted thoracoscopy might be an option.The standard abdominal approach is the median laparotomy. Bleeding control can be achieved by hiatal aortic cross-clamping and packing of the abdomen, followed by a systematic exploration. If necessary, a laparostomy must be established. Moreover, if chest injuries are ruled out, the resuscitative endovascular balloon occlusion of the aorta (REBOA) can be considered as a bridge to surgery.Whether projectiles, fragments, or shrapnels require removal depends on the location and the potential complications of tissue dissection. Penetrating injuries due to blasts and gunshots are always contaminated.

Hardly any other speciality is as fraught with tension as emergency medicine. In addition to the need to have a broad spectrum of knowledge about illnesses and injuries, the time factor is particularly important. Emergency physicians have to quickly gain an overview of their patients' condition. Mostly without having all the information about the patient's medical history, long-term medication or previous findings. Decisions have to be made under time pressure. In addition to experience and knowledge, the targeted use of the available diagnostic options is essential for quick treatment decisions. A detective-like approach is sometimes required here, particularly in order to confirm suspected diagnoses and rule out differential diagnoses by using focussed diagnostics. Clinical experience, training and the odd "trick" lay the foundation for skillfully using the diagnostic options at the right time for the right patient - i.e. point-of-care - and finding the right diagnosis. Aha!

The severity and extent of gunshot and blast injuries are often misjudged due to a lack of specialist knowledge. The aim of this article is to outline the characteristics of gunshot and blast injuries, including emergency diagnostics and initial surgical treatment.Due to multiple high-energy penetrating injuries, barotrauma, or blunt trauma, affected patients are usually polytraumatized, with multiple organ damage and an average Injury Severity Score (ISS) of > 36. In addition to the complexity of the wounds, they are characteristically severely contaminated. After pre-hospital treatment, life-threatening injuries and conditions should be identified and initially treated in the trauma room phase. The procedure should be based on a standardized, internal hospital emergency medical and emergency surgical algorithm. Damage control surgery can then be used to treat acutely life-threatening complications of gunshot and blast injuries in order to prevent the fatal triad and the occurrence of further early complications. Examples of interventions include debridement and decontamination, fracture stabilization (external fixators and splints), surgical decompression (skull, thorax, compartment syndromes) and surgical hemostasis.

Gunshot and blast injuries are extremely rare in the emergency services. However, in the context of the increasing threat of terrorist attacks, the possibility of these traumas is also coming into focus. This article provides an overview of the various entities and the corresponding treatment principles for penetrating injuries.