#2 ESPRESSO-FOLGE: Pneumothorax Diagnostik – Röntgen Thorax oder Lungen Ultraschall?

05/20/22 • 6 min

Intensivtalk – von Medizinern für Mediziner

Was sagen die aktuellen Leitlinien zur Detektion eines Pneumothorax nach Trauma oder auch nach ZVK Anlage? Passt das zur aktuellen Evidenz? Wir geben Euch in dieser Folge – unserer ersten Espresso-Folge – einen Handlungsleitfaden.
Literaturangaben
Wilkerson R.G.
Stone M.B.
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010; 17: 11-17 https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00628.x
Bridwell RE, Long B, Gottlieb M. Is Chest Ultrasonography Superior to Supine Chest Radiography in Identifying Pneumothorax in Emergency Department Trauma Patients? Ann Emerg Med. 2021 Jun;77(6):646-648. doi: 10.1016/j.annemergmed.2020.09.437. Epub 2020 Oct 27. PMID: 33121833. https://doi.org/10.1016/j.annemergmed.2020.09.437
S3-Leitlinie Diagnostik und Therapie von Spontanpneumothorax und postinterventionellem Pneumothorax. AWMF-Register Nr. 010-007, https://www.awmf.org/leitlinien/detail/ll/010-007.html
S3-Leitlinie Polytrauma / Schwerverletzten-Behandlung AWMF-Register Nr. 012-019 https://www.awmf.org/leitlinien/detail/ll/012-019.html

Vorherige Episode

#1 Temperaturmanagement nach Reanimation auf der Intensivstation

Hypothermie oder Normothermie oder nur Fiebervermeidung? Was ist „State of the Art“ des Temperaturmanagements (TTM, target temperature management) auf der Intensivstation nach Reanimation? Was steht in den Leitlinien? Wie ist die aktuelle Studienlage? Unsere Experten für Intensivmedizin Dr. med. Oliver Hofer (Chefarzt Intensivstation), Dr. med. Matthias Leiter (Oberarzt Intensivstation) und Dr. med. Sven Kürten (Oberarzt Intensivstation) bringen Licht ins Dunkel dieser wichtigen klinischen Fragestellung und geben Euch einen evidenzbasierten Handlungsleitfaden.
Shownotes | Literaturangaben
Gräsner JT, Herlitz J, Tjelmeland IBM et al (2021) European resuscitation council guidelines 2021: epidemiology of cardiac arrest in europe. Resuscitation 161:61–79
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N EnglJ Med 2002;346:557-563https://www.nejm.org/doi/full/10.1056/NEJMoa003289
The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-556 https://www.nejm.org/doi/full/10.1056/NEJMoa012689
Nielsen N., Wetterslev J., Cronberg T., Erlinge D., Gasche Y., Hassager C., et al. (2013). Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N. Engl. J. Med. 369 2197–2206. 10.1177/2048872619870031 - DOI - PubMed https://www.nejm.org/doi/10.1056/NEJMoa1310519?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
Salter R, Bailey M, Bellomo R, Eastwood G, Goodwin A, Nielsen N, Pilcher D, Nichol A, Saxena M, Shehabi Y, Young P; Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS-CORE). Changes in Temperature Management of Cardiac Arrest Patients Following Publication of the Target Temperature Management Trial. Crit Care Med. 2018 Nov;46(11):1722-1730. doi: 10.1097/CCM.0000000000003339. PMID: 30063490.
Dankiewicz J, Cronberg T, Lilja G, et al Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med 2021;384:2283-2294. https://www.nejm.org/doi/full/10.1056/NEJMoa2100591
Fischer M, Wnent J, Gräsner JT et al (2021) Öffentlicher Jahresbericht 2020 des Deutschen Reanimationsregisters: Außerklinische Reanimation 2020 www.reanimationsregister.de/berichte
Lascarrou, J. B., Meziani, F., Le Gouge, A., Boulain, T., Bousser, J., Belliard, G., Asfar, P., Frat, J. P., Dequin, P. F., Gouello, J. P., Delahaye, A., Hssain, A. A., Chakarian, J. C., Pichon, N., Desachy, A., Bellec, F., Thevenin, D., Quenot, J. P., Sirodot, M., Labadie, F., ... Clinical Research in Intensive Care and Sepsis (CRICS) Group and HYPERION Study Group (2015). Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial. Scandinavian journal of trauma, resuscitation and emergency medicine, 23, 26. https://doi.org/10.1186/s13049-015-0103-5
Awad, A., Taccone, F.S., Jonsson, M. et al. Time to intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest patients and its association with neurologic outcome: a propensity matched sub-analysis of the PRINCESS trial. Intensive Care Med 46, 1361–1370 (2020). https://doi.org/10.1007/s00134-020-06024-3
Kirkegaard H, Søreide E, de Haas I, et al. Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2017;318(4):341–350. doi:10.1001/jama.2017.8978
Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial | Emergency Medicine | JAMA | JAMA Network

Nächste Episode

#3 Volumentherapie auf der Intensivstation

Von „in doubt give volume“ hin zur Beurteilung der Mikrozirkulation – Paradigmenwechsel in der Volumentherapie des Intensivpatienten. Von „rivers“ über die Trilogie der großen Multicenter-Studien (ARISE, PROCESS, PROMISE) und „cry my a river“ hin zu Poincare-2. Wir diskutieren in dieser Folge des Intensivtalks die wahrscheinlich anspruchsvollste Frage in der Intensivmedizin: Welche Menge an kristalloider Infusionslösung tut gut und welche Menge schadet? Zudem wie kann die Zukunft der Steuerung der Volumentherapie aussehen? Wie erfolgversprechend sind intravitale Zungenmikroskopie oder Messung der pCO2-Gap?
Literaturangaben
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal‐directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–1377.
The ARISE Investigators, ANZICS Clinical Trials Group (2014) Goal-directed resuscitation for patients with early septic shock. New Engl J Med 371:1496–1506
The ProCESS Investigators (2014) A randomized trial of protocol-based care for early septic shock. New Engl J Med 370:1683–1693
The ProMISe Investigators (2015) Trial of early, goal-directed resuscitation for septic shock. New Engl J Med 372:1301–1311
Seymour, Christopher W.; Gesten, Foster; Prescott, Hallie C.; Friedrich, Marcus E.; Iwashyna, Theodore J.; Phillips, Gary S.; Lemeshow, Stanley; Osborn, Tiffany; Terry, Kathleen M.; and Levy, Mitchell M.,"Time to treatment and mortality during mandated emergency care for sepsis." The New England Journal of Medicine. 376,23. 2235-2244. (2017).
Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen. AWMF-Register 001/020. 2014
Eskesen, T.G., Wetterslev, M. & Perner, A. Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 42, 324–332 (2016).
Evans, L., Rhodes, A., Alhazzani, W. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 47, 1181–1247 (2021).
Haas, S.A., Lange, T., Saugel, B. et al. Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients. Intensive Care Med 42, 202–210 (2016). https://doi.org/10.1007/s00134-015-4127-0
Groner, W., Winkelman, J., Harris, A. et al. Orthogonal polarization spectral imaging: A new method for study of the microcirculation. Nat Med 5, 1209–1212 (1999). https://doi.org/10.1038/13529
Hernandez G et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized trial. JAMA. 2019 Feb 19;321(7):654-664
Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, van der Voort PHJ, Dondorp AM, Bafi T, Fries M, Akarsu-Ayazoglu T, Pranskunas A, Hollenberg S, Balestra G, van Iterson M, Sadaka F, Minto G, Aypar U, Hurtado FJ, Martinelli G, Payen D, van Haren F, Holley A, Gomez H, Mehta RL, Rodriguez AH, Ruiz C, Canales HS, Duranteau J, Spronk PE, Jhanji S, Hubble S, Chierego M, Jung C, Martin D, Sorbara C, Bakker J, Ince C; microSOAP study group. Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis. Crit Care. 2017 Oct 18;21(1):255. doi: 10.1186/s13054-017-1842-7. PMID: 29047411; PMCID: PMC5646128.
Cuschieri J, Rivers EP, Donnino MW, Katilius M, Jacobsen G, Nguyen HB, Pamukov N, Horst HM. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med. 2005 Jun;31(6):818-22. doi: 10.1007/s00134-005-2602-8. Epub 2005 Apr 1. PMID: 15803301.
Zhou J, Song J, Gong S, Li L, Zhang H, Wang M. Persistent hyperlactatemia-high central venous-arterial carbon dioxide to arterial-venous oxygen content ratio is associated with poor outcomes in early resuscitation of septic shock. Am J Emerg Med. 2017 Aug;35(8):1136-1141. doi: 10.1016/j.ajem.2017.03.027. Epub 2017 Mar 14. PMID: 28341187.