Spering Christopher, Lehmann Wolfgang
Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Göttingen, Göttingen, Deutschland.
Zentralbl Chir. 2024 Aug;149(4):368-377. doi: 10.1055/a-2348-0638. Epub 2024 Aug 7.
Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥ 3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At < 4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, > 6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.
严重胸部创伤可表现为穿透性或钝性单一损伤，也可是多发伤的一部分。在创伤注册数据库DGU记录的所有重伤患者中，近一半被诊断为严重胸部创伤，根据简明损伤定级标准（AIS）定义为≥3级。在我们自己的病例组中，这一比例甚至更高，达60%。在德国，于创伤复苏单元内或入院后第一小时内行开胸急诊手术治疗极为罕见，占严重胸部损伤的0.9%。复杂多发伤的处理、对创伤的广泛病理生理反应以及对继发性损伤发展的认识，使得人们得出结论，诸如电视辅助胸腔镜手术（VATS）或插入胸腔引流管等微创手术可解决大多数严重胸部创伤。胸部穿透伤发生率低于4%，较为罕见。在钝性胸部损伤中，超过6%表现为胸壁不稳定，需要手术重建。德国的人口结构变化导致损伤模式发生转变。低能量创伤的发生率低于胸膜、肺、心包/心肌和膈肌穿透性肋骨骨折等更严重的胸壁损伤。这有时会导致胸壁不稳定，严重限制呼吸力学，进而引发暴发性肺炎甚至急性呼吸窘迫综合征（ARDS）。在此背景下，过去十年来手术胸壁重建变得越来越重要。连同有力的基础证据，对创伤范围和严重程度以及呼吸功能损害程度的评估是决定非手术或手术重建策略以及手术时机、类型和范围的结构化决策的基础。72小时内早期手术可降低发病率（肺炎发生率、重症监护和通气持续时间）和死亡率。在接下来的文章中，将在严重胸部损伤的管理背景下讨论基于证据的手术和非手术策略算法。因此，针对严重胸部损伤、胸壁重建的适应证、治疗策略和治疗建议的主要出版物进行了选择性文献检索。
