Ziegenfuss T
Klinik für Anaesthesiologie und Intensivmedizin, Universität des Saarlandes Homburg/Saar.
Zentralbl Chir. 1996;121(11):924-42.
Adequate prehospital care of the severely traumatised patient is important to prevent or attenuate early as well as late life threatening complications, such as tissue hypoxia, ischemia/reperfusion injury and finally multiple organ failure. A mismatch of oxygen supply and oxygen demand is a hallmark in the pathophysiology of multiple trauma. Oxygen supply may be diminished by the following factors: shock-related decrease of cardiac output, anemia and hypoxia. On the other hand, oxygen demand may be increased by pain, panic, and agitation. Hence, it is a central point in prehospital care to reduce this supply-demand imbalance by identification and prompt reversal of the underlying causes. Most often, shock is caused by hypovolaemia and tissue injury ("traumatic-hemorrhagic shock"). However, shock may also be a result of central nervous system injury (neurogenic shock as a special form of distributive shock) or circulatory obstruction, e.g tension pneumothorax or cardiac tamponade (obstructive shock). Volume resuscitation by means of crystalloid or colloid solutions is an essential part in the therapy of the traumatic-haemorrhagic shock. In addition, catecholamines may be necessary in order to achieve an adequate arterial pressure. However, if bleeding cannot be controlled in the prehospital setting, only moderate volume support and permissive hypotension as well as rapid transportation into the next hospital may be preferable. This may be the case in penetrating thoracic or abdominal injuries as well as in traumatic amputations of the proximal limb. On the contrary, in patients with severe head injury, hypotension must be avoided by all means. Obstructive shock has to be treated urgently by insertion of a chest drain or drainage of the pericardium, respectively. Under all circumstances, it is an essential part of prehospital therapy to provide sufficient analgesia as soon as possible. Prehospital anesthesia, combined with artificial ventilation may be necessary for optimal patient management. Furthermore, ventilatory support is indicated when respiratory failure, loss of consciousness, or severe shock are present. Additional oxygen should be given whenever possible, even in the absence of an overt hypoxic state. Important additional measures are cervical spine immobilisation and reposition as well as splinting of long bone fractures or luxations, in order to avoid secondary injury of the spinal cord or ongoing tissue and vascular damage.
对严重创伤患者进行充分的院前护理对于预防或减轻早期以及晚期危及生命的并发症至关重要，如组织缺氧、缺血/再灌注损伤以及最终的多器官功能衰竭。氧供需不匹配是多发伤病理生理学的一个标志。氧供应可能因以下因素而减少：与休克相关的心输出量下降、贫血和缺氧。另一方面，疼痛、恐慌和躁动可能会增加氧需求。因此，通过识别并迅速扭转潜在病因来减少这种供需失衡是院前护理的核心要点。最常见的情况是，休克由低血容量和组织损伤（“创伤性出血性休克”）引起。然而，休克也可能是中枢神经系统损伤（神经源性休克，作为分布性休克的一种特殊形式）或循环阻塞的结果，例如张力性气胸或心脏压塞（梗阻性休克）。通过晶体或胶体溶液进行容量复苏是创伤性出血性休克治疗的重要组成部分。此外，可能需要使用儿茶酚胺以达到足够的动脉压。然而，如果在院前环境中出血无法得到控制，那么仅进行适度的容量支持和允许性低血压以及迅速转运至下一家医院可能更为可取。穿透性胸腹部损伤以及近端肢体创伤性截肢可能属于这种情况。相反，对于重度颅脑损伤患者，必须千方百计避免低血压。梗阻性休克必须分别通过插入胸腔引流管或心包引流进行紧急治疗。在任何情况下，尽早提供充分的镇痛都是院前治疗的重要组成部分。为了实现最佳的患者管理，可能需要进行院前麻醉并结合人工通气。此外，当出现呼吸衰竭、意识丧失或严重休克时，需要进行通气支持。即使没有明显的缺氧状态，只要有可能就应给予额外的氧气。重要的额外措施包括颈椎固定和复位以及长骨骨折或脱位的夹板固定，以避免脊髓继发性损伤或持续的组织和血管损伤。
