Penetrierende Verletzungen - eine wachsende Gefahr in Westeuropa

Abstract

BACKGROUND: Penetrating injuries (PI) in Germany are rising slowly but steadily. Because of their great variety there is still a need for treatment algorithms adjusted to german infrastructure. METHODS: 199 patients with penetrating injuries, treated from 1986 to 2005, were analysed with the aid of a questionnaire retrospectively. After literature review and evaluation of our results we developed some policies of mandatory therapeutic interventions. RESULTS: In 42 gunshot, 144 stab and 2 combined gunshot and stab wound injuries chest and abdomen were the most often injured regions. Chest x-ray (54.3 %) and ultrasound (49.5 %) were the most frequent diagnostic procedures. 61.7 % of all patients were operated within 24 h. Out of 73 thoracic PI we performed thoracic surgery in 27.4 %, 30.1 % were treated only with a chest tube, the remaining were observed closely. Out of 78 abdominal PI laparoscopy was performed in 35.9 %; in 31 % the latter conversion to laparotomy was necessary. 64.1 % were operated by laparotomy. 22 % of the laparotomies were of explorative character. In only 57.7 % injuries of the abdominal organs could be found. Altogether the complication rate was 28.7 % and the mortality as low as 1.6 %. In 11 impalements the rectum and perineal region was injured most often in 64 %, only 9 % developed septic complications. CONCLUSIONS: Based on appropriate diagnostic procedures we recommend a selective management for stab and gunshot wounds, which also includes minimal invasive procedures as therapy standards. Patients in shock have to be treated immediately surgical. In thoracic injuries chest tube application is of high diagnostic and therapeutic significance. Thoracotomy should performed in blood loss ≥ 1 500 ml. Thoracoscopy is indicated in blood loss ≤ 1 500 ml, clotted hemothorax and persistent pneumothorax. Supposed cardiac injuries require immediate sternotomy. Laparoscopy should be used in abdominal stab wounds to exclude peritoneal penetration and gives also therapeutic options. For supposed intestinal leckage and gunshot wounds laparotomy is the golden standard. In abdominal gunshots only tangential wounds can be managed without laparotomy. Therapy of rectal impalements includes primary closure, presacral drainage, colostomy and wound debridement.