Schussverletzungen – Diagnostik und Therapie in der Präklinik

 

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Zusammenfassung

In der Notfallmedizin tätige Ärzte in Deutschland haben, verglichen mit den USA, nur relativ geringe Erfahrungen mit Schussverletzungen. Dieser Beitrag vermittelt Basiswissen über die verschiedenen Schusswaffen und die damit hervorgerufenen unterschiedlichen Verletzungen, um bereits präklinisch eine gezielte Diagnostik und erste therapeutische Schritte einleiten zu können.

Abstract

In spite of the gunshot rampages in Germany in the recent years, gunshot wounds are rare in Germany and cannot be compared to the high number of nonfatal gunshot wounds in the United States of America.
To understand the injury caused by bullets hitting a human body some facts about wound ballistics have to be known. The grade of injury depends on the bullet properties as well as the properties of the hidden tissue. The higher the amount of energy the bullet is transferring to the body, the higher is the damage caused in the human tissue. All gunshot wounds are contaminated. But even though this is a well-known fact, there is no consensus about the surgical treatment in literature. While most authors recommend a debridement and an antibiotic therapy, in some areas of the world uncomplicated gunshot wounds are treated with sterile wound dressing and a single shot of antibiotics.
In a preclinical setting the main goal to go for with gunshot wounds is to stop the bleeding. In recent years the tourniquet became a routine tool in the preclinical stage to achieve this. New haemostyptic wound dressings show promising results in the treatment of bleeding wounds as well, even though there are still some unanswered questions. Beside that the preclinical treatment should follow the military-modified PHTLS algorithm.

• Literatur

• 1 US Centers for Disease Control & Prevention (CDC). Web-Based Injury Statistics Query & Reporting System (WISQARS). Atlanta: Nonfatal Injury Reports; 2016
  MissingFormLabel

  Suche in Google Scholar
• 2 Stefanopoulos PK, Pinialidis DE, Hadjigeorgiou GF. et al. Wound ballistics 101: the mechanisms of soft tissue wounding by bullets. Eur J Trauma Emerg Surg 2015;
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 3 Coupland R. Clinical and legal significance of fragmentation of bullets in relation to size of wounds: retrospective analysis. BMJ 1999; 319: 403-406
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 4 Fackler ML, Dougherty PJ. Theodor Kocher and the scientific foundation of wound ballistics. Surg Gynecol Obstet 1991; 172: 153-160
  MissingFormLabel

  PubMedSuche in Google Scholar
• 5 von See C, Stuehmer A, Gellrich NC. et al. Wound ballistics of injuries caused by handguns with different types of projectiles. Mil Med 2009; 174: 757-761
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 6 Hauer T, Huschitt N, Kulla M. et al. [Bullet and shrapnel injuries in the face and neck regions. Current aspects of wound ballistics]. HNO 2011; 59: 752-764
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 7 Fackler ML. Gunshot wound review. Ann Emerg Med 1996; 28: 194-203
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 8 Kneubuehl B. Wound Ballistics: Basics and Applications. Translation of the 3rd german edition. Berlin: Springer; 2011
  MissingFormLabel

  CrossrefSuche in Google Scholar
• 9 Breeze J, Sedman AJ, James GR. et al. Determining the wounding effects of ballistic projectiles to inform future injury models: a systematic review. J R Army Med Corps 2014; 160: 273-278
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 10 Payne LD. Military wound ballistics: history and renaissance. J R Army Med Corps 2013; 159: 256-258
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 11 Riddez L. Wounds of war in the civilian sector: principles of treatment and pitfalls to avoid. Eur J Trauma Emerg Surg 2014; 40: 461-468
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 12 Bluman EM, Ficke JR, Covey DC. War wounds of the foot and ankle: causes, characteristics, and initial management. Foot Ankle Clin 2010; 15: 1-21
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 13 Giannou C, Baldan M. War Surgery: Working with limited Resources in armed Conflict and other Situations of Violence. Vol. 1. Geneva: ICRC; 2010
  MissingFormLabel

  CrossrefSuche in Google Scholar
• 14 Albreht M, Scepanovic D, Ceramilac A. et al. Experimental soft tissue wounds caused by standard military rifles. Acta Chir Scand Suppl 1979; 489: 185-198
  MissingFormLabel

  PubMedSuche in Google Scholar
• 15 Fackler ML, Bellamy RF, Malinowski JA. A reconsideration of the wounding mechanism of very high velocity projectiles – importance of projectile shape. J Trauma 1988; 28: S63-S67
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 16 King KF. Orthopaedic aspects of war wounds in South Vietnam. J Bone Joint Surg Br 1969; 51: 112-117
  MissingFormLabel

  PubMedSuche in Google Scholar
• 17 Suneson A, Hansson HA, Seeman T. Pressure wave injuries to the nervous system caused by high-energy missile extremity impact: Part II. Distant effects on the central nervous system – a light and electron microscopic study on pigs. J Trauma 1990; 30: 295-306
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 18 Weinstein J, Putney E, Egol K. Low velocity gunshot wounds result in significant contamination regardless of ballistic characteristics. Am J Orthop (Belle Mead NJ) 2014; 43: E14-E18
  MissingFormLabel

  PubMedSuche in Google Scholar
• 19 Hopkinson DA, Marshall TK. Firearm injuries. Br J Surg 1967; 54: 344-353
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 20 Dickey RL, Barnes BC, Kearns RJ. et al. Efficacy of antibiotics in low-velocity gunshot fractures. J Orthop Trauma 1989; 3: 6-10
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 21 Woloszyn JT, Uitvlugt GM, Castle ME. Management of civilian gunshot fractures of the extremities. Clin Orthop Relat Res 1988; 226: 247-251
  MissingFormLabel

  Suche in Google Scholar
• 22 Wright DG, Levin JS, Esterhai JL. et al. Immediate internal fixation of low-velocity gunshot-related femoral fractures. J Trauma 1993; 35: 678-681
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 23 Kobbe P, Frink M, Oberbeck R. et al. [Treatment strategies for gunshot wounds of the extremities]. Unfallchirurg 2008; 111: 247-254
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 24 NAEMT. American College of Surgeons Committee on Trauma. PHTLS Prehospital Trauma Life Support: military Edition. 7th ed. Burlington: Jones & Bartlett Learning; 2010
  MissingFormLabel

  CrossrefSuche in Google Scholar
• 25 Hodgetts TJ, Mahoney PF, Russell MQ. et al. ABC to <C>ABC: redefining the military trauma paradigm. Emerg Med J 2006; 23: 745-746
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 26 Deutsche Gesellschaft für Unfallchirurgie. S3-Leitlinie Polytrauma-/Schwerverletzten-Behandlung 2016. Im Internet: http://www.awmf.org/leitlinien/detail/ll/012-019.html Stand: 15.05.2017
  MissingFormLabel
• 27 Kue RC, Temin ES, Weiner SG. et al. Tourniquet use in a civilian emergency medical services setting: a descriptive analysis of the Boston EMS Experience. Prehosp Emerg Care 2015; 19: 399-404
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 28 Scerbo MH, Mumm JP, Gates K. et al. Safety and appropriateness of tourniquets in 105 civilians. Prehosp Emerg Care 2016; 20: 712-722
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 29 McEwen JA, Kelly DL, Jardanowski T. et al. Tourniquet safety in lower leg applications. Orthopaedic Nursing 2002; 21: 55-62
  MissingFormLabel

  PubMedSuche in Google Scholar
• 30 Swan jr. KG, Wright DS, Barbagiovanni SS. et al. Tourniquets revisited. J Trauma 2009; 66: 672-675
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 31 Josse F, Helm M, Kulla M. et al. Präklinische Blutstillungsmaßnahmen: Hämostyptika. Notarzt 2015; 31: 153-157
  MissingFormLabel

  Thieme ConnectSuche in Google Scholar
• 32 Lechner R, Helm M, Mueller M. et al. Efficacy of hemostatic agents in humans with rotational thromboelastometry: an in-vitro study. Mil Med 2016; 181: 907-912
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 33 Travers S, Lefort H, Ramdani E. et al. Hemostatic dressings in civil prehospital practice: 30 uses of QuikClot Combat Gauze. Eur J Emerg Med 2016; 23: 391-394
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 34 Gegel BT, Austin PN, Johnson AD. An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control. AANA J 2013; 81: 453-458
  MissingFormLabel

  PubMedSuche in Google Scholar
• 35 Bieler D, Franke AF, Hentsch S. et al. [Gunshot and stab wounds in Germany – epidemiology and outcome: analysis from the TraumaRegister DGU^®]. Unfallchirurg 2014; 117: 995-1004
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 36 Bretschneider I, Hossfeld B, Helm M. et al. Präklinisches Atemwegsmanagement beim Erwachsenen. Notarzt 2011; 27: 270-286
  MissingFormLabel

  Thieme ConnectSuche in Google Scholar
• 37 Schubl SD, Robitsek RJ, Sommerhalder C. et al. Cervical spine immobilization may be of value following firearm injury to the head and neck. Am J Emerg Med 2016; 34: 726-729
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 38 Clemency BM, Tanski CT, Rosenberg M. et al. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehosp Disaster Med 2015; 30: 249-253
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 39 Helm M, Hossfeld B, Schlechtriemen T. et al. [Use of intraosseus infusion in the German air rescue service : nationwide analysis in the time period 2005 to 2009]. Anaesthesist 2011; 60: 1119-1125
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 40 Harris T, Thomas GO, Brohi K. Early fluid resuscitation in severe trauma. BMJ 2012; 345: e5752
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 41 Hasler RM, Nuesch E, Juni P. et al. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: multicentre cohort study. Resuscitation 2011; 83: 476-481
  MissingFormLabel

  PubMedSuche in Google Scholar