J. A. Sturm

5. Die Belastbarkeit Mehrfachverletzter und ihre Bedeutung für die operative Versorgung

Treatment of severely injured patients requires exact planning and mature management. For practical reasons the classification into 4 phases has been introduced: acute, primary, secondary and tertiary phases. During the acute phase all life-saving operations are performed. In the primary, secondary and tertiary phases the procedures vary according to priority. Reviewed on the basis of 781 severely injured patients, the most reliable criteria are: pulmonary artery pressure, creatinine, bilirubin, extravascular lung water, the PaO2/FiO2 quotient and fluid balance.SummaryTreatment of severely injured patients requires exact planning and mature management. For practical reasons the classification into 4 phases has been introduced: acute, primary, secondary and tertiary phases. During the acute phase all life-saving operations are performed. In the primary, secondary and tertiary phases the procedures vary according to priority. Reviewed on the basis of 781 severely injured patients, the most reliable criteria are: pulmonary artery pressure, creatinine, bilirubin, extravascular lung water, the PaO2/FiO2 quotient and fluid balance.ZusammenfassungDie Behandlung Schwer- und Mehrfachverletzter erfordert eine exakte Planung und ein ausgereiftes Management. Bewährt hat sich die Einteilung in Akut-, Primär-, Sekundär- und Tertiärphase. In der Akutphase werden alle lebenserhaltenden Maßnahmen durchgeführt. In der Primär-, Sekundär- und Tertiärphase folgen dann die übrigen Eingriffe. Aufgrund einer Untersuchung an 781 Schwerstverletzten haben sich für die Indikationsstellung als wesentliche Parameter der Pulmonalarteriendruck, das Kreatinin, das Bilirubin, die Flüssigkeitsbilanz und das extravasale Lungenwasser herausgestellt sowie der Quotient aus PaO2 und inspiratorischer Sauerstoffkonzentration.

Phagocytic function of polymorphonuclear leukocytes and the RES in endotoxemia

The reticuloendothelial system (RES) and the polymorphonuclear leukocytes (PMNs) are thought to play a major role in defense against sepsis. Disturbances in the function of these two phagocytic systems during a septic event is associated with the development of lung capillary injury. Endotoxemia is said to lead to similar changes. Our study examined the function of the RES and PMNs after bolus injection of endotoxin (2 micrograms/kg BW) in a standardized sheep model. For up to 24 hr after endotoxin, blood samples were drawn and PMN function was followed by chemiluminescence, chemotaxis, and adherence as well as the phagocytosis and killing of bacteria. RES function was determined by the blood clearance of a labeled Tc99 colloid. We found an increase of RES clearance directly after endotoxin. Chemotaxis, phagocytosis, and killing were reduced. Adherence was increased. Chemiluminescence peak maximum (CLPM), representing the metabolic activity of the PMNs, was initially increased but shortly thereafter showed a significant decline (at 1 hr: 0.52 +/- 0.13 X 10(6) cpm with P less than 0.05 compared to baseline). The chemiluminescence peak time (CLPT), a measure of membrane receptor function, was significantly reduced (10.0 +/- 2.2 min with P less than 0.001 compared to baseline). Endotoxin led to a reduction of intracellular PMN functions (phagocytosis, killing, CLPM) within 1 hr. Membrane localized functions (adherence, CLPT) were increased. The changes in PMN function might be the reason for the development of lung capillary injury, in spite of undisturbed RES clearance.

57. Die primäre Oberschenkelosteosynthese beim Polytrauma: Gefahr oder Gewinn für den Patienten?

SummaryIn a retrospective study we compared polytraumatized patients with femural fractures after primary osteosynthesis (group 1) with patients after late internal fixation or conservative treatment (group 2). Group 1 needed a significantly shorter time of mechanical ventilation and lower PEEP values. In case of an additional thoracic injury the risk for group 1 was tremendously increased. Early osteosynthesis of a femur fracture in polytraumatized patients has a positive effect. In case of additional thoracic trauma conservative treatment or late operation should be preferred.ZusammenfassungBei einer retrospektiven Untersuchung an Polytraumatisierten mit Femurfraktur fanden wir, daß nach primärer Osteosynthese eine significant kürzere Beatmungszeit und ein niedrigerer PEEP erforderlich war als nach verzögerter Osteosynthese bzw. konservativer Behandlung. Bei gleichzeitig vorliegendem Thoraxtrauma brachte eine primäre Osteosynthese jedoch eine höhere Gefährdung der Patienten mit sich. Die primäre Osteosynthese einer Oberschenkelfraktur bei Polytraumen hat einen günstigen Einfluß auf den Verlauf, ausgenommen Patienten mit zusätzlichem Thoraxtrauma.

2. Die prognostische Bedeutung der Frühversorgung am Beispiel des Unfallpatienten

Progress in the therapeutic management of multiple trauma patients has led to a decline in mortality (now 20%). The main cause for death is still the multiple organ failure (MOF), which is initiated in an early phase after trauma by shock and tissue damage, and manifests in a late phase during posttraumatic sepsis. Humoral and cellular changes accelerate the capillary damage, which provokes the failure of the organ systems. For this reason all therapeutic efforts should aim to minimize these influences. Next to infusion and ventilation therapy, early definite reduction of bleeding and tissue damage (debridement) and early osteosynthesis in multiple trauma patients seems reasonable.SummaryProgress in the therapeutic management of multiple trauma patients has led to a decline in mortality (now 20%). The main cause for death is still the multiple organ failure (MOF), which is initiated in an early phase after trauma by shock and tissue damage, and manifests in a late phase during posttraumatic sepsis. Humoral and cellular changes accelerate the capillary damage, which provokes the failure of the organ systems. For this reason all therapeutic efforts should aim to minimize these influences. Next to infusion and ventilation therapy, early definite reduction of bleeding and tissue damage (debridement) and early osteosynthesis in multiple trauma patients seems reasonable.ZusammenfassungFortschritte in der Versorgung von Polytraumatisierten haben zu einer Senkung der Letalität auf ca. 20% geführt. Haupttodesursache bleibt das Multiorganversagen (MOV), welches in einer Frühphase nach Unfall durch Schock und Gewebsschaden initiiert und in einer Spätphase durch die posttraumatische Sepsis manifestiert wird. Humorale und celluläre Veränderungen beschleunigen den Capillarschaden und damit das spätere Organversagen. Alle therapeutischen Bemühungen sollten daher der Minimierung dieser genannten Einflüsse dienen. Neben Infusionsund Beatmungstherapie müssen Blutungen und Weichteilschäden frühzeitig beherrscht und eine frühe osteosynthetische Versorgung angestrebt werden.

Der Einfluß des kontinuierlichen axialen Lagewechsels bei der Behandlung des posttraumatischen Lungenversagens (ARDS)

ZusammenfassungDas posttraumatische Lungenversagen stellt nach wie vor eine gefürchtete Komplikation dar. Aufgrund guter Erfahrungen mit einer kontinuierlichen axialen Lagerungstherapie in einem Spezialbett verglichen wir eine Gruppe von ARDS-Patienten, die nach Verschlechterung der Lungenfunktion mit Hilfe des Spezialbetts (Fa. KCI-Mediscus, Hoechstadt) gelagert wurde (Gruppe KIN), mit in herkömmlicher Rückenlage beatmeten Patienten mit ARDS (Gruppe KON). Folgende Parameter wurden täglich bestimmt: extravaskuläres Lungenwasser (EVLW, mittels Doppelindikatorverdünngsmethode), Oxygenierung (PaO2/FiO2) und berechnete Werte aus hämodynamischen Messungen mittels Pulmonalarterienkatheter. Bei Erreichen eines Oxygenierungsquotienten (PaO2/FiO2) von 150 wurde die kontinuierliche axiale Lagerung (beidseitige Rotation um die Körperlängsachse bis 62°) durchgeführt. Elf KIN-Patienten und elf KON-Patienten wurden in die Studie aufgenommen. Die Gesamtverletzungsschwere nach dem Injury Severity Score (ISS) betrug 29,6±6 Punkte in der KIN-Gruppe und 31,6±5 Punkte in der KON-Gruppe. Der Oxygenierungsquotient verbesserte sich signifikant innerhalb von fünf Tagen nur in der KIN-Gruppe (Tag 0: 140±45; Tag 5: 237±40) (p<0,05), bei KON-Patienten war keine Verbesserung feststellbar (Tag 0: 143±48, Tag 5: 133±44, p<0,05, im Gruppenvergleich). Die pulmonale Shuntfraktion field signifikant nur in der Gruppe KIN(Tag 0: 26,6±4%; Tag 5: 12,5±2%) und betrug bei KON-Patienten 36,6±6% am Tag 0 und 31,4±2% am Tag 5 (p<0,05 im Gruppenvergleich). Das extravaskuläre Lungenwasser stieg nur in der Gruppen KON im Vergleich zum Studienbeginn (Tag 0: 12,9±2 ml/kg KG; Tag 5: 17,4±3 ml/kg KG). Kontinuerliche axiale Lagerungswechsel bei Patienten mit posttraumatischem ARDS verbessert die Lungenfunktion und reduziert den intrapulmonalen Rechts-links-Shunt. Negative hämodynamische Nebeneffekte treten beim Lagerungswechsel nicht auf. Der kontinuierliche axiale Lagerungswechsel stellt eine erwägenswerte unterstützende Therapie für Patienten mit posttraumatischem ARDS dar.AbstractIn the treatment of posttraumatic adult respiratory distress syndrome (ARDS) so far no breakthrough has been achieved. In several cases of severe ARDS we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and hemodynamics in ARDS patients to conventional (KON) supine positioning. 22 ARDS patiens with multiple trauma treated by supportive continuous body positioning (KIN) (KCI-Mediscus) and without continuous positioning (KON) were investigated daily. Pulmonary and systemic hemodynamics were determined on the basis of pulmonary artery catheter measurements. Oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Qs/Qt, %) were calculated. Extravascular lung water (EVLW, ml/kg body weight) was determined by double indicator thermodilution technique. Total injury severity by injury severity score (ISS) was 29.6±6 points (KIN) and 31.6±5 points (KON). The oxygenation ratio (PaO2/FiO2) increased significantly from 140±45 (day 0) to 237±40 (p<0.05) [day 5] (KIN), in KON patients no improvement (143±48 [day 0], 133±44 [day 5]) was seen (p<0.05 between groups). There were no significant changes of systemic hemodynamics between the groups or compared to day 0. Pulmonary shunt decreased significantly from 26.6±4% (day0) to12.5±2% (day5) (p<0.05) in KIN patients and was 36.6±6% at day 0 and 31.4±2% at day 5 in KON patients (p<0.05 between groups). EVLW was 11.1±2 ml/kg body weight at day 0 and 9.4±1 ml/kg body weight at day 5 (KIN)-EVLW was 12.9±2 ml/kg body weight at day 0 and 17.4±3 ml/kg body weight at day 5 (KON) (not significant). We found no hemodynamic side effects from continuous body positioning. In ARDS-patients submitted to body positioning oxygenation and pulmonary shunt improved significantly and were significantly better compared to those with conventional supine positioning. Continuous body positioning appears to represent a promising supportive treatment regimen in posttraumatic ARDS.In the treatment of posttraumatic adult respiratory distress syndrome (ARDS) so far no breakthrough has been achieved. In several cases of severe ARDS we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and hemodynamics in ARDS patients to conventional (KON) supine positioning. 22 ARDS patients with multiple trauma treated by supportive continuous body positioning (KIN) (KCI-Mediscus) and without continuous positioning (KON) were investigated daily. Pulmonary and systemic hemodynamics were determined on the basis of pulmonary artery catheter measurements. Oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Qs/Qt,%) were calculated. Extravascular lung water (EVLW, ml/kg body weight) was determined by double indicator thermodilution technique. Total injury severity by injury severity score (ISS) was 29.6 +/- 6 points (KIN) and 31.6 +/- 5 points (KON). The oxygenation ratio (PaO2/FiO2) increased significantly from 140 +/- 45 (day 0) to 237 +/- 40 (p < 0.05) [day 5] (KIN), in KON patients no improvement (143 +/- 48 [day 0], 133 +/- 44 [ay 5]) was seen (p < 0.05 between groups). There were no significant changes of systemic hemodynamics between the groups or compared to day 0. Pulmonary shunt decreased significantly from 26.6 +/- 4% (day 0) to 12.5 +/- 2% (day 5) (p < 0.05) in KIN patients and was 36.6 +/- 6% at day 0 and 31.4 +/- 2% at day 5 in KON patients (p < 0.05 between groups). EVLW was 11.1 +/- 2 ml/kg body weight at day 0 and 9.4 +/- 1 ml/kg body weight at day 5 (KIN)-EVLW was 12.9 +/- 2 ml/kg body weight at day 0 and 17.4 +/- 3 ml/kg body weight at day 5 (KON) (not significant). We found no hemodynamic side effects from continuous body positioning. In ARDS-patients submitted to body positioning oxygenation and pulmonary shunt improved significantly and were significantly better compared to those with conventional supine positioning. Continuous body positioning appears to represent a promising supportive treatment regimen in posttraumatic ARDS.

Klinisch-experimentelle Untersuchungen zum oxidativen Membranschaden nach schwerem Trauma

Beim pulmonalen Permeabilitatsschaden nach schwerem Trauma und nach Sepsis wird der unkontrollierten Reaktion von O2-Radikalen, gebildet von aktivierten polymorphkernigen neutrophilen Leukocyten (PMNL) eine wesentliche Schadigung der Zellmembran zugesprochen (2). Der Nachweis von Lipidperoxiden, ein Produkt des oxidativen Membranschadens, ist bislang im Lungengewebe nach schwerem Trauma noch nicht erfolgt. Die kausale Beteiligung der PMNL mit O2-Radikal-Produktion ist nicht erwiesen. Es war daher unser Ziel, zum einen den oxidativen Membranschaden an der Lunge nach schwerem Trauma durch gesteigerte Lipidperoxidation nachzuweisen und zum anderen die Fahigkeit der kausal beteiligten Zellen, der PMNL, Sauerstoffradikale zu generieren, zu uberprufen.

Multiorganversagen nach Trauma: Frühe Dysregulation der spezifischen und unspezifischen Immunabwehr

Die Entwicklung eines Multiorganversagens mit Immundefektsyndrom stellt eine haufig letale Komplikation nach schwerem Polytrauma dar. Sowohl im spezifischen als auch im unspezifischen Immunsystem konnten bereits deutliche Veranderungen nach schwerem Trauma nachgewiesen werden. Storungen der Interaktionen zwischen beiden Immunabwehrsystemen im posttraumatischen Verlauf sind noch nicht ausreichend geklart. Vor allem gibt es keine Untersuchungen in der fur die Pathogenese des sekundaren Immundefektes wichtigen Fruhphase nach Polytrauma.

Suppression of the neutrophil chemiluminescence response in blood of multiply traumatized patients with and without the adult respiratory distress syndrome (ARDS)

ConclusionsFrom the results, alterations of humoral and cellular components of the nonspecific immune system were supposed to be involved in the ARDS pathogenesis. Concerning the intravascular compartment, a plasma opsonin defect could be observed, especially for group C patients with a later EVLW increase. Furthermore, these patients demonstrated a continuous synthesis of a trauma factor that suppressed CL responses and presumably also phagocytosis/killing functions of PMNL in blood, hereby predisposing this patient group to sepsis and sepsis-amplified ARDS development. Such an inhibition factor has been described by Lanser et al. [5] in septic patients, but our results demonstrated that this factor seemed always to be synthetized after a traumatic event irrespective of septicemia. As a consequence, the increased endogenous respiratory burst potential of neutrophils, especially of patients with a later EVLW increase, becomes effective after the neutrophil has left the capillary and entered the alveolar space, no longer being kept in check by the trauma factor and then liberating the complete set of inflammation mediators for lung structure damage.

Lungenembolierisiko nach intravenöser Heparin-Prophylaxe beim polytraumatisierten Patienten

SummaryThe risk of thrombo-embolic complications in multiple injured patients is increased due to several pathophysiological factors. The purpose of this study was to analyse the effect of a continuous IV heparin prophylaxis (10000IE/24h) in polytraumatized patients. A post-mortem evaluation of 72 deceased patients out of 373 multiple trauma patients treated during 1984–1985 was performed. In one patient multiple major pulmonary emboli were found to contribute to his death. No deep vein thrombosis as well as no fulminant pulmonary embolism were found in any case.ZusammenfassungDas Risiko thromboembolischer Komplikationen ist beim Polytrauma infolge verschiedener pathophysiologischer Vorgänge erhöht. Ziel dieser Studie war es den Einfluß einer kontinuierlichen IV Heparin-Prophylaxe (10 000 IE/24h) beim Polytrauma zu untersuchen. Retrospektiv wurden 72 obduzierte Todesfälle von 373 Polytraumen aus den Jahren 1984 und 1985 analysiert. Bei einem Patienten waren multiple periphere Makrolungenembolien für den Tod mitverantwortlich. Fulminante Lungenembolien, Becken- und tiefe Beinvenenthrombosen wurden im Sektionsgut nicht gefunden.The risk of thrombo-embolic complications in multiple injured patients is increased due to several pathophysiological factors. The purpose of this study was to analyse the effect of a continuous IV heparin prophylaxis (10000IE/24h) in polytraumatized patients. A post-mortem evaluation of 72 decreased patients out of 373 multiple trauma patients treated during 1984-1985 was performed. In one patient multiple major pulmonary emboli were found to contribute to his death. No deep vein thrombosis as well as no fulminant pulmonary embolism were found in any case.

246. Eine funktionelle Untersuchung der polymorphkernigen Granulocyten nach Polytrauma — Schädigungsmechanismen im capillar-alveolären Abschnitt

SummaryThe polymorphonuclear leucocytes (PMNL) are supposed to play a major role in the development of the acute respiratory distress syndrome (ARDS) after multiple trauma. Upon stimulation, they produce toxic metabolites that increase the capillary permeability. The functional state in which this production occurs is unknown. To clarify the mechanisms of pathogenesis, we examined the function of PMNL before and after passage through the endothelial membrane, using specimens of whole blood and bronchoalveolar lavage (BAL) washings. Chemiluminescence was measured in ten polytraumatized patients, and showed a decrease of PMNL functional activity in the BAL fluid. These results correlate well with the release from PMNL of toxic metabolites, which seem to lead to endothelial damage, possibly causing ARDS.ZusammenfassungDie neutrophilen Granulocyten sollen eine bedeutende Rolle bei der Entwicklung des ARDS nach Polytrauma spielen. Nach Stimulation produzieren diese nämlich toxische Metabolite, die die Capillarpermeabilität erhöhen. Unklar ist, in welchem funktionellen Status diese Produktion stattfindet. Zur Aufklärung dieser Pathomechanismen untersuchten wir die Funktion dieser PMNL vor (im Vollblut) und nach (broncho-alveoläre Lavage) Passage durch die Endothelmembran. 10 polytraumatisierte Patienten zeigten dabei eine Abnahme der funktionelllen Aktivität dieser Zellen in der BAL. Diese Ergebnisse korrelieren mit der Ausschüttung der toxischen Metabolite, welches zu dem Endothelschaden führt und wahrscheinlich Grund für die ARDS-Entwicklung ist.