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Schussverletzungen: Müssen Projektile und Fragmente immer entfernt werden?

Gunshot wounds: should projectiles and fragments always be removed?

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Zusammenfassung

Hintergrund

Bei Schussverletzungen jedweder Körperregion kann es zum Verbleib von kompletten Projektilen oder deren Fragmenten im Körper resp. in den Extremitäten kommen. Ist die Zerlegung eines Projektils eingetreten, muss auch bei Vorliegen eines Ausschusses mit dem Verbleib von Bruchstücken des Mantels oder eines bleihaltigen Kerns in der Trefferzone gerechnet werden.

Ziel der Arbeit/Fragestellung

Es stellt sich im Rahmen der chirurgischen Versorgung dieser Verletzungen regelmäßig die Frage, ob die operative Entfernung von Projektilen oder Fragmenten grundsätzlich medizinisch indiziert ist.

Material und Methoden

Anhand typischer Fälle aus dem eigenen Patientengut und unter Berücksichtigung der speziellen Literatur wird dargestellt, welche speziellen Konstellationen und grundsätzlichen Empfehlungen bezüglich der Entfernung von Projektilen vorliegen. Die Parameter für die Indikationsstellung einer chirurgischen Entfernung werden in einem Algorithmus aufgezeigt.

Ergebnisse

Im Rahmen einer klinischen Nachuntersuchung wurden 5 Verletzte mit verbliebenen Schrotkugeln kontaktiert und Serumproben sowie 24-Stunden-Sammelurin analysiert, um eine systemische Belastung mit Blei auszuschließen. Wir konnten so durchschnittlich 74 Monate (max. 128 bis min. 42) nach der Verletzung Bleispiegel im Serum von im Mittel 8,25 μg/ml dokumentieren. Die δ-Aminolävulinsäure im Urin lag durchschnittlich bei 4,8 mg/24 h. Eine signifikante Erhöhung beider Werte konnten wir somit nicht nachweisen.

Diskussion

Bei verbliebenen, relevanten bleihaltigen Projektilen oder Fragmenten ist ein Monitoring über die Bestimmung des Bleispiegels im Serum sowie der Aminolävulinsäure im Urin angezeigt. Die wichtigsten klinischen Symptome einer Bleiintoxikation etablieren sich gastrointestinal und neurologisch. Bei etablierter Bleivergiftung ist die Detoxikation mit Chelatbildnern die Therapie der Wahl, verbunden mit der Elimination der Bleiquelle durch eine operative Revision.

Abstract

Background

Projectiles or metal fragments can remain lodged in the body of victims of gunshot injuries. This also applies to projectiles which do not tend to deform or fragment on impact. When a projectile fragments on penetration, jacket or lead core particles are likely to remain lodged in the affected region even if the projectile has exited the body.

Aim of the study

A frequently asked question in the surgical management of such injuries is whether there are medical indications for the surgical removal of projectiles or fragments.

Material and methods

This article presents some typical cases of patients who have received treatment at our institution and reviews the pertinent literature to show general recommendations in special cases concerning the removal of projectiles or fragments and when additional surgical trauma is justified. Parameters for decision making are presented in an algorithm.

Results

From our own patients, 5 with remaining fragments in the soft tissue were invited for a clinical follow up. Serum probes and 24 h urine output was analysed for serum lead levels and urinary aminolevulinic acid levels. 74 months (max. 128 – min. 42 months) after injury we documented not elevated serum lead levels of 8.25 μg/ml and urinary aminolevulinic acid levels of 4.8 mg/24 h.

Discussion

When lead-containing projectiles or fragments remain lodged in the body, monitoring is required and includes the measurement of serum lead levels and urinary aminolevulinic acid levels. The most important clinical symptoms of lead poisoning are gastrointestinal and neurological in nature. The treatment of choice for lead poisoning is the administration of chelating agents and removal of the lead source by surgical intervention.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. E. Kollig, S. Hentsch, A. Willms, D. Bieler und A. Franke geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland

    E. Kollig, S. Hentsch, A. Willms, D. Bieler & A. Franke

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  1. E. Kollig
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  2. S. Hentsch
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  3. A. Willms
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Correspondence to E. Kollig.

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Kollig, E., Hentsch, S., Willms, A. et al. Schussverletzungen: Müssen Projektile und Fragmente immer entfernt werden?. Chirurg 85, 607–615 (2014). https://doi.org/10.1007/s00104-013-2643-4

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