Biomedical subjects

S Ruchholtz

Publications and source records attributed to S Ruchholtz.

At least 55 records · Page 3Linked to original sources

PubMed1998

Improvement in the therapy of multiply injured patients by introduction of clinical management guidelines.

A trauma algorithm representing the guidelines for the management of emergency treatment of severe blunt trauma was implemented at our institution in 1994. By comparison of two prospectively recorded cohorts of multiply injured patients, the clinical efficacy of these guidelines was analysed. The algorithm cohort comprised 74 patients over the period January 1994 to June 1996, and the Control cohort 126 patients over the period April 1988 to December 1993. To evaluate procedural quality of early clinical trauma management, nine criteria were applied. After implementation of the algorithm there was an improvement in all parameters reflected by a significant reduction of missed injuries and important time savings. Mortality rates in the cohorts were calculated after subdivision into three groups (I-III) with moderate (ISS: 18-24), high (ISS: 25-49) and very high (ISS: 50-75) injury severity. All cohort subgroups were comparable with respect to ISS values, age, initial loss of consciousness (GCS) and shock rate. In all subgroups of the algorithm cohort mortality rates were reduced: group I: 0 versus 20 per cent (p < 0.05); group II: 8 versus 24 per cent (p < 0.05); group III: 40 versus 71 per cent. Improvements in both therapeutic process and outcome were observed after implementation of the trauma algorithm.

Adult↗

PubMed1998

Percutaneous computed tomographic-controlled ventriculostomy in severe traumatic brain injury.

OBJECTIVE: Percutaneous computed tomographic (CT)-controlled ventriculostomy (PCV) was introduced for the monitoring of intracranial pressure in patients with severe traumatic brain injury who did not require simultaneous decompressive trepanation. METHODS: PCV (n = 14) was compared with conventional burr hole ventriculostomy (n = 13) based on prospectively collected data. RESULTS: PCV proved to be a successful technique in all cases and also when a burr hole ventriculostomy was impossible previously. There were no complications. In burr hole ventriculostomy, there were one unsuccessful insertion and one catheter contamination. The main advantage of PCV over burr hole ventriculostomy was a significant (p < 0.05) reduction in the time required to perform the procedure. In ventriculostomy directly after the initial evaluation in the emergency department, the operation time was reduced from 45 +/- 11 to 22 +/- 14 minutes. The interval between cranial computed tomography and start of operation was reduced from 78 +/- 38 to 33 +/- 12 minutes, and between initial cranial computed tomography and intensive care unit admittance, from 138 +/- 37 to 73 +/- 28 minutes. For patients requiring ventriculostomy while being treated in the intensive care unit, the duration of the procedure (i.e., absence from the intensive care unit) was able to be reduced from 111 +/- 24 to 81 +/- 21 minutes. CONCLUSION: Distinct time savings are the major advantages of PCV, allowing exact catheter positioning even with very narrow ventricles.

Adolescent↗

PubMed1998

[Effect of kinetic therapy on the course of treatment of patients with post-traumatic lung failure].

This study was conducted to investigate the effects of intermittent prone positioning of patients with post-traumatic respiratory failure (paO2/FiO2 < 280 mm Hg) in comparison with conventional therapy in a supine position. Although the severity of injury of the prone-positioned patients was much higher (ISS 35.8 vs 24.5), the ventilation time (32 vs 31 days) and ICU stay (39 vs 36 days) were similar to patients treated in the supine position. Besides the beneficial effect of prone positioning on oxygenation, for the first time we have evidence that prone positioning improves the outcome of patients with post-traumatic respiratory failure.

Adult↗

PubMed1998

[Minimal invasive, percutaneous ventriculostomy in therapy of severe craniocerebral trauma].

From May 1996 until April 1997 percutaneous CT-controlled ventriculostomy (PCV) was performed in 19 patients with severe traumatic brain injury and no indication for decompressive craniotomy. There was a significant reduction in the duration of the procedure compared to burr-hole ventriculostomy with no complications. Because of further advantage of PCV CT-controlling is the possibility of puncturing even very narrow ventricles.

Brain Edema↗

PubMed1997

[Treatment of Pipkin fractures].

Because of the controversy that exists about therapy for the Pipkin fracture, the treatment and results of 117 fractures of the femoral head were reviewed and re-evaluated at least 1 year after the trauma had taken place. The cases were taken from eight publications in the literature from 1983 to 1995. The lesions in this collection comprised 35% (n = 41) type I, 40% (n = 47) type II, 10% (n = 12) type III and 15% (n = 17) type IV fractures classified after the Pipkin system. Seventy-four percent of patients (n = 87) were operated on; only type I lesions were treated conservatively in 42%, thus more often than average. There were 57 complications with equally frequent head necroses (14.5%) and severe coxarthritis. Coxarthritis was doubled after conservative treatment versus operation (23% vs. 13%). There was no difference in respect to head necrosis. Postoperatively, 18 (14%) periarticular ossifications were registered. Forty-one (75%) of 55 Pipkin I and II fractures had an at least "good" outcome; the portion of conservative treatment was higher than operative treatment (88% vs 69%). Still these results have to be seen with respect to the use of treating simple lesions primarily conservatively with the minimum of 6 weeks of traction therapy, thus counting the latter patients in this group. According to the literature, we think that if there are no vital contraindications, all Pipkin fractures should be treated operatively (early emergency operation) by reattaching bigger fragments and extracting smaller fragments in Pipkin I and II fractures, trying to save the heads in young, active patients with Pipkin III fractures in contrast to primary endoprosthesis in elderly patients with coxarthrosis with Pipkin IV fractures (unstable and displaced fractures of the acetabulum).

Femur Head↗

PubMed1997

[Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis?].

PROBLEM: The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three-and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. PATIENTS AND METHODS: Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The "X" represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7-72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P < 0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P < 0.05). RESULTS: Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P < 0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer),but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6-12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. CONCLUSION: In displaced three-and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered.

Adult↗

PubMed1997

[Quality management in early clinical multiple trauma care. Documentation of treatment and evaluation of critical care quality].

Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm. The quality of present data recording was analysed, and criteria for judgement of quality of care were assessed. The algorithm was divided into 117 possible steps (one step consisting of a single decision criterion, the decision and the corresponding procedure). Per patient, only 61% +/- 12% of these steps were sufficiently documented to allow judgement. Using several criteria for assessment, the following baseline data could be observed (times shown refer to admission to the trauma room): (1) trauma room time of 129 +/- 55 min; (2) completion of basic radiological and sonographic diagnostics in 91% of patients; (3) first blood collection after 17 +/- 11 min; (4) cranial computerised tomography after 55 +/- 20 min; (5) missed injuries during the trauma room period in 32% of patients; (6) intubation after 20 +/- 19 min; (7) insertion of a chest tube after 30 +/- 17 min; (8) first blood transfusion in shock after 32 +/- 17 min; (9) transfused blood within the first hour of 4.2 +/- 2.8 units and within the second hour of 8.5 +/- 4.7 units; (10) emergency operations in shock after 98 +/- 55 min; (11) early operations after 156 +/- 69 min; (12) craniotomy after 124 +/- 37 min; (13) unplanned surgery within 24 hours after admission to the intensive care unit in 11% of patients. The study presented here supplies information on timing and other process data of the acute clinical care of seriously injured patients. In particular, the data represent indicators for the quality of emergency room management, which may be used as baseline to compose improvement measures of structure and process. The quality of data collection has to be improved for carrying out an exact analysis of the process.

Adolescent↗

PubMed1997

[Quality management in early clinical polytrauma management. II. Optimizing therapy by treatment guidelines].

To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3% vs. 12%. The lethality rates of each collective were assessed after subdivision in three groups (I-III) with middle (ISS: 18-24), high (ISS: 25-49) and extreme (ISS: 50-75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0% vs. 20% (P < 0.05); group II, 8% vs. 24% (P < 0.05); and group III, 40% vs. 71%, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.

Adult↗

PubMed1997

[Algorithms in trauma management].

A well-controlled, meticulous process has a far higher probability of resulting in a high quality of medical care than improvization and unstructured creativity. Algorithms display decision-making treatment processes and problem-solving strategies by giving clearly defined and formalized guidelines. The flow chart for decision-making follows the yes/no dichotomy of binary logic. The systematic ordering of decision points and consequent actions is guided by medical priority and thus regulates the time-frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. Clinical algorithms represent scientifically recognized treatment rules, indicate a solution for solving problems and help users to organize ideas and recognize connections. They delineate a consistent and valid guideline, while allowing deviations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured means of problem solving for the less experienced user. Algorithms are useful instruments in the teaching of medical decision-making.

Algorithms↗

PubMed1997

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND: Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS: Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS: The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS: These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Adolescent↗

PubMed1997

[Evaluation and quality management in multiple trauma care].

In total quality management of polytraumatised patients, it is necessary to use analysis of structure, process and outcome quality to search for problem areas and improvement possibilities. The structure includes the attributes of material and human resources. The process denotes the real treatment course with the demand for treatment guidelines (algorithm) and an exact documentation of treatment. To prove the outcome quality, an internal and external judgement is possible. Our own results show that quality assessment, concerning the process as well as the internal and external quality outcome, brings a significant improvement to the care of polytrauma patients.

Algorithms↗

PubMed1997

[A time and priority-oriented algorithm].

Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. They delineate a consistent and valid guideline but require aberrations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured way of problem-solving to the less experienced user. Algorithms are useful instruments in teaching medical decision-making.

Algorithms↗

PubMed1997

[Shock room management in severe craniocerebral trauma].

Early clinical management of severe head injury should take place in an emergency resuscitation room and be conducted according to the guidelines of the treatment of severely injured patients with attention given to time. The first phase (with a maximum duration of 30 min) comprises physical examination, stabilisation of vital functions and basic technical diagnostics. With pulmonary and circulatory functions stabilized, the second phase begins with a craniol computed tomography examination followed by adequate therapeutic measures, including, if necessary, the CT-controlled implantation of an intracranial pressure catheter.

Brain Edema↗

PubMed1997

[The trauma register of the 'Polytrauma' Committee of the German Society of Trauma Surgery as the basis for quality management in the management of severely injured patients].

The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in respect to the treatment criteria (i.e., duration of basic diagnostics in severe trauma) and quality of outcome (TRISS method and Z statistic) were revealed for some clinics. The feedback of their data offers the associated clinics the possibility of identification of treatment phases that are worth being optimized.

Germany↗

PubMed1996

[The injury pattern in polytrauma. Value of information regarding accident process in clinical acute management].

To investigate the correlation between the mechanism of an accident and the resulting injury pattern we reviewed the data of 195 prospectively documented multiply traumatized patients. Information on the accident was based on descriptions given by eye witnesses, police and the emergency medical staff. Only moderate to severe lesions (AIS > or = 3; Abbreviated Injury Scale Version 1990) of each body region were analyzed. The mean injury severity (ISS) for all these patients was 39.5 (18-75); the lethality was 34%. Different types of accidents led to various injury patterns. We found a high incidence of lesions of the head in frontal (F) motor vehicle crashes (MVC) nonbelted (76%), of the chest in lateral (L) MVCs (80%), of the abdomen in F MVCs belted and in LMVCs (60%), of the pelvis after suicidal fall (SF; 69%) and of the lower extremities in motorcycle accidents (90%), SFs (69%) and collisions with a train (67%). Severe lesions of the spine were frequently seen after accidental falls (41%), SFs (30%) and F MVCs belted (25%). There was a very substantial difference in the injury pattern after suicidal jump (26% head, 69% pelvis, 65% lower extremity lesions). and accidental fall (54% head, 19% pelvis, 23% lower extremity lesions). As a result of the correlation with specific injury patterns, the preceding mechanism of accident should be exactly documented and considered by the physician during the early phase of resuscitation.

Abbreviated Injury Scale↗

PubMed1996

[Intramedullary nailing of lower leg fractures with minimal soft tissue injuries].

The importance of intramedullary nailing (IM) for closed and type I tibial shaft fractures is evaluated on the basis of a review of the recent literature (1991-1996) and the data on 61 patients that underwent a reamed (RTN; n = 31) or an unreamed (UTN; n = 26) procedure. There was no difference between the two groups in age, fracture type or localization. Soft tissue trauma prevailed with 38% type I open fractures in the UTN group (RTN group, 3%). Both groups showed about the same proportion of good and very good results (criteria of Johner and Wruhs; 89% RTN and 88% UTN), which corresponds to the results of other authors (83%-96% RTN; 79%-96% UTN). The rate of nonunions is about the same with 6% (RTN) and 4% (UTN), respectively, and there were no infections. In accordance with the literature, we found earlier osseous reunion after unreamed nailing (RTN = 18 weeks vs UTN = 12 weeks). This corresponds to early, painless, full weight-bearing after an average of 10.3 as opposed to 13.8 weeks in the RTN group. Except for earlier osseous reunion reamed and unreamed TN proved to be equivalent procedures. As a precondition, if more endostium is affected, reaming should be performed after stabilization of the soft tissue damage, and fractures of the metaphysis should be interlocked in two dimensions (using all interlocking possibilities) if treated with the more unstable UTN, along with reduced weight-bearing for at least 6 weeks. The implant should be chosen in compliance with individual demands, taking the higher intramedullary stability of the RTN into consideration and the endostium-preserving insertion of the UTN.

Bone Nails↗

PubMed1996

[Preclinical diagnosis and management in severe craniocerebral trauma].

Both prehospital and hospital management of patients with severe head injury has clearly improved in the last decades. There is a greater knowledge of how secondary brain injury is caused and how it can be prevented. Intracranial mechanisms (e.g. haematoma and elevated intracranial pressure and systemic mechanism (e.g. shock and hypoxaemia) are two of the major causes of secondary brain injury. Adequate prehospital evaluation and treatment determine the later outcome for the patient. The Glasgow Coma Scale has become the standard score for assessing the level of consciousness. Early prehospital treatment must prevent secondary brain damage through adequate oxygenation (intubation, ventilation) and a sufficient cerebral perfusion pressure (treatment of shock). The neck of the patient should be positioned straight and the upper part of the body should be elevated to about 30 degrees. The prophylactic use of steroids, mannitol or high dose barbiturates is not indicated. Aggressive hyperventilation (pCO2 < 30 mmHg), especially during the first few days after severe brain injury, should be avoided.

Brain Damage, Chronic↗

PubMed1996

[Severe craniocerebral trauma].

In medical services where acute accident patients are encountered, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the Department of Surgery at the University Hospital in Munich, we have been performing neurotraumatological treatment since 1983. We had 162 patients with severe head and brain injuries, 95 intracerebral contusional bleeding, 8 depression fractures, and 3 hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 68 patients and osteoclastic trepanation in 65. Further interventions were elevation of the 8 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurosurgical surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1 cured; 2 slightly; 3 severely handicapped; 4 vegetative state; 5 expired). The Traumatic Coma Data Bank (1991) recorded the outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.

Adolescent↗