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PubMed2007

[Teaching and simulation. Methods, demands, evaluation and visions].

Since 1st October 2003 the new German "Approbationsordnung für Arzte" (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training program. Basic requirements for a successful training program using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor-student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios "induction of anaesthesia", "acute pulmonary embolism", "acute management of a multiple trauma patient" and "postoperative hypotension" as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1-6. These scores were better than those given for other segments of the curriculum.

Anesthesia↗
PubMed2004

Dexmedetomidine infusion without loading dose in surgical patients requiring mechanical ventilation: haemodynamic effects and efficacy.

We investigated the haemodynamic effects and the efficacy of a continuous infusion of dexmedetomidine without a loading dose in 50 patients having had cardiac surgery (n = 33), complex major surgery (n = 9) and multiple trauma (n = 8). The mean age was 60 (+/- 16) years, and the mean APACHE II score was 13 (+/- 5). Dexmedetomidine was commenced at an initial rate of 0.2 to 0.4 microg/kg/h (depending on whether anaesthetic or sedative agents had already been used) and rescue analgesia and sedation was administered with morphine and midazolam respectively. Propofol was used if additional sedation was needed. Sedation was targeted to a modified Motor Activity Assessment Score. Eighty percent of patients required no or "minimal" rescue therapy (< 10 mg midazolam/day and/or < 10 mg morphine/day and/or < 100 mg propofol/day). The cardiac surgery group needed the least rescue therapy. A statistically significant but clinically unimportant reduction in mean heart rate and mean systolic blood pressure was observed over the first six hours (P < 0.0001, and P = 0.009 respectively). The baseline heart rate of 85 (+/- 17) beats per minute (bpm), fell to a low of 78 (+/- 13) bpm at four hours and then remained stable throughout the infusion period. The systolic blood pressure fell from 125 (+/- 22) mmHg to a low of 112 (+/- 20) mmHg at 1.5 hours with minimal change afterwards. Dexmedetomidine was an effective sedative and analgesic in this group of complex surgical and trauma patients with pronounced benefit in the cardiac surgery group. Omitting the loading dose avoided undesirable haemodynamic effects without compromising sedation and analgesia.

Adult↗
PubMed1995

[Does initial management of polytrauma patients have an effect on the development of multiple organ failure? Evaluation of preclinical and clinical data of 1,112 polytrauma patients].

The aim of this study was to investigate criteria in the preclinical and early clinical treatment which contribute to the development of posttraumatic multiple organ failure (MOV). In a retrospective study, 1112 primarily treated patients with multiple trauma and an injury severity > 20 on the Hanover Polytrauma Score (PTS) were investigated. The patients were classified according to Goris into groups with MOV (+MOV; 16.8%) and without MOV (-MOV). Patients with MOV had a significantly higher injury severity score (39.1 vs 33.7). A significantly higher proportion of +MOV patients had severe trunk injuries: thorax (85.2% vs 68.9%), abdomen (37.0% vs 26.1%) and pelvis (49.4% vs 35.6%). -MOV patients had significantly more injuries of the extremities (83.6% vs 72.8%). Differences in preclinical management were seen. The proportion of helicopter transports was significantly higher in the -MOV group (67.9% vs 57.8%). A positive effect was seen for early preclinical intubation. Patients who were intubated before arrival at the hospital had the same rate of MOV incidence as late intubated patients, but they had significantly higher (trunk) injury severity. +MOV patients received a significantly higher quantity of fluid replacement. In particular, more blood units and fresh frozen plasma were given in the first 24 h after trauma, possibly in association with the trunk injuries and the consequently increased hemorrhage. The mortality for all patients was 27.2%, in the +MOV group 60.4%. Posttraumatic MOV was the most frequent cause of death (37.5%), and the mean time of death after MOV was 16.7 days.

Adult↗
PubMed1990

Acute mannitol intoxication in a patient with normal renal function.

A young, previously healthy patient with multiple trauma mistakenly received 400 grams of mannitol over a 3-hour period. The laboratory report of hyponatremia prompted treatment with hypertonic saline before the hyperosmolar state was recognized. The osmolal gap was 118. Mannitol intoxication in a patient without preexisting renal failure is unusual. Identification of an abnormal osmolal gap and recognition of the hyperosmolar state is discussed.

Accidents, Traffic↗
PubMed1990

Thoracic spine fractures.

Diagnosis of thoracic spine fractures in patients with multiple trauma requires careful evaluation of the chest radiograph. Primary findings, consisting of a fracture line through the vertebral bodies, decreased height of the vertebral body, an increase in the interpediculate distance and misalignment of the vertebral bodies, may all be noted on the anteroposterior supine chest radiograph. Early diagnosis and intervention may prevent a catastrophic neurologic event, such as spinal cord or nerve root damage.

Fractures, Bone↗
PubMed1997

Cardiac herniation producing tamponade: the critical role of early diagnosis.

BACKGROUND: Rupture of the pleuropericardium (PP) occurs rarely, with most patients dying of associated injuries before arriving at the hospital. Among patients who initially survive, the diagnosis is often delayed until cardiogenic shock secondary to cardiac herniation is evident. METHODS: The records of 10 patients with PP lacerations and cardiac herniations were reviewed. RESULTS: All but one patient had a normal chest x-ray (CXR) film on admission. After the patients became symptomatic, seven of nine had abnormal findings on CXR film demonstrating herniation of the heart into the left hemithorax. The other two patients underwent surgery without a repeat CXR film. Except for one who was taken directly to the operating room, all patients had been previously stabilized before developing cardiogenic shock, on average 9 hours after admission. Operative therapy was closure of the pericardium for five patients and completion pericardiotomy for the others. All survivors developed significant complications, and four of them died. CONCLUSIONS: The diagnosis of PP rupture should be considered for patients with multiple trauma who develop sudden and unexpected cardiogenic shock after their initial condition has been stabilized. A repeat CXR film is diagnostic in most cases and should be used as the most efficient and expeditious route to making the diagnosis.

Accidents, Traffic↗
PubMedDate not supplied

Transfusion rates vary significantly amongst Canadian medical centres.

PURPOSE: To document variation of transfusion practice following repair of hip fracture or cardiac surgery, as well as those requiring intensive care following a surgical intervention or multiple trauma (high risk patients). METHODS: We documented rates of allogeneic red cell transfusion in 41,568 patients admitted to 11 hospitals across Canada between August 1998 and August 2000 as part of a retrospective observational cohort study. In the subgroup of 7,552 patients receiving red cells, we also compared mean nadir hemoglobin concentrations from centre to centre. RESULTS: The overall rate of red cell transfusion was 38.7%, and ranged from 23.8% to 51.9% across centres among the 41,568 perioperative and critically ill patients. Women were more likely to be transfused (43.7% vs 35.3%, P < 0.0001), with higher rates of transfusion in eight of 11 centres. Compared to a chosen reference hospital having a crude transfusion rate near the median, the adjusted odds of transfusion ranged from 0.44 to 1.53 overall, from 0.42 to 1.22 in patients undergoing a hip fracture repair, from 0.72 to 3.17 in cardiac surgical patients undergoing cardiac surgery, and from 0.27 to 1.11 in critically ill and trauma patients. In the 7,552 transfused patients, the mean adjusted nadir hemoglobin was 74.0 +/- 4.83 g x L(-1) overall, and ranged from 66.9 +/- 1.7 g x L(-1) to 84.5 +/- 1.6 g x L(-1) across centres. Similar differences among centres were observed amongst hip fracture patients (71.2 +/- 2.9 g x L(-1) to 82.8 +/- 1.7 g x L(-1)), cardiac surgical patients (65.7 +/- 1.1 g x L(-1) to 77.3 +/- 1.0 g x L(-1)) and critically ill and trauma patients (66.1 +/- 3.04 g x L(-1) to 87.5 +/- 2.5 g x L(-1)). CONCLUSION: We noted significant differences in the rates of red cell transfusion and nadir hemoglobin concentrations in various surgical and critical care settings.

Adolescent↗
PubMed1995

Preventing posttraumatic pneumonia.

Between 20% and 40% of patients admitted to the hospital with multiple trauma develop bacterial pneumonias. The most immediate causes are aspiration, blunt chest trauma, and prolonged immobilization. Traumatic shock and the need for immediate head and chest surgery are contributing factors. Signs of systemic infection, infiltrates on the chest film, and microbiological evidence obtained from sputum samples are the principal diagnostic criteria. Prophylactic measures include aseptic management of the airway, tracheostomy when indicated, adequate pain relief, and early mobilization. When the incipient signs of pneumonia appear, prompt aggressive antimicrobial therapy is indicated.

Bacterial Infections↗
PubMed1994

[Acute hydrops of the gallbladder in childhood].

The authors discuss four cases of acute hydrops of the gallbladder being examined in the Department of Pediatrics, Medical University School of Pécs. Diagnosis was based on ultrasonography. In all cases right upper quadrant abdominal pain and fatigue were observed. The causes of hydrops were Kawasaki's disease, sepsis, and multiple trauma. In one case the cause was unknown. In one of the cases cholecystectomy was done, in three cases the hydrops resolved spontaneously. The authors discuss the aetiology, the symptomatology and the therapeutical possibilities of hydrops. On the basis of their results the authors suggest the importance of the serial ultrasound examinations.

Acute Disease↗
PubMed1993

[Change in the procedure from external fixator to intramedullary nailing osteosynthesis of the femur and tibia].

Shaft fractures of femur and tibia can be treated successfully by intramedullary nailing. In recent years the use of interlocking nails widened the indication for nailing fractures of the proximal and distal bone and more difficult fractures. There are still limits in polytrauma patients, chain fractures with or without participation of joints and in fractures with severe soft tissue injury (open or closed). In these cases primary treatment with external fixation has proved worthwhile. The main problems and risks of primary nailing osteosynthesis occur in the early phase of treatment, whereas complications in external fixation are more likely to occur in later phases of treatment. In changing from external fixation to intramedullary nailing one can see the advantages of both methods. In the literature only small studies have been made mostly with patient groups below 50 in number. The change of method was rarely standardised and the time period between procedures was either late (more than 3 weeks) or arbitrary. The advantages and disadvantages as well as the risk in changing methods are controversial. In a 2-year prospective study from August 1989 to July 1991, patients with II and III degree open and closed femur and tibia fractures as well as trauma patients with fractures were initially treated by external fixation. A change of method from external fixation to intramedullary nailing was performed at the earliest possible time under exact criteria. 61 femur and 106 tibia fractures were accordingly treated and followed. In comparison to early studies there were no differences in bone healing or in functional results. The infection rate in tibia fractures was 1.9% (2 of 106); no infection was seen in femur fractures. The contamination rate at the time of method change was substantially higher at 14%. The difference between contamination and infection rate can be explained by experience in the technique of nailing, considering biological aspects (no or little reaming), the standardized change of method and the prophylactic use of antibiotics. In a follow-up of additional 37 femur and 58 tibia fractures that were treated accordingly, a total infection rate of 1.9% was achieved (2% in femur fractures [n = 98], 1.8% in tibia fractures [n = 164], 1.9% total [n = 262]). In femur and tibia fractures with open or closed soft tissue damage and in multiple trauma patients the treatment with initial stabilisation by external fixation and secondary change to intramedullary nailing can be recommended under certain conditions.

Adolescent↗
PubMed1994

Prevention of postoperative venous thromboembolism: an update.

BACKGROUND: Perioperative venous thromboembolism remains a major health problem. Each year, approximately 260,000 cases are diagnosed clinically, and the incidence of asymptomatic and undiagnosed cases is far greater. Despite the availability of effective strategies to prevent venous thromboembolism, prophylaxis is underutilized. According to recent epidemiologic surveys, approximately two thirds of hospitalized patients with clinical risk factors for venous thromboembolism do not receive adequate prophylaxis. METHODS: A comprehensive review of the English language literature was carried out to define effective antithrombotic regimens to prevent venous thromboembolism in discrete surgical patient populations. Reliable data are available for every group with the exception of patients with multiple trauma and spinal cord injury. CONCLUSIONS: A wide variety of effective prophylactic methods are available to prevent venous thromboembolism. Individual patients can be assigned a level of risk based on clinical risk factors. The choice of prophylactic method is based on the level of risk, potential for complications, and costs. With the wide availability of proven methods, no patient at risk for venous thromboembolism should be left unprotected.

Brain↗
PubMed2006

Paediatric spinal trauma and associated injuries.

Paediatric spinal injuries, although rare (1-2% of all paediatric fractures) are associated with the highest mortality rate of all orthopaedic injuries in children. The low incidence is due, not only to the plasticity of the paediatric spine, but also the difficulty of diagnosis and the usually severe if not fatal associated injuries. A 10-year (1995-2004) retrospective study was undertaken of all patients treated for a spinal injury at our institute, which functions as both an acute care centre and a tertiary referral centre for seriously injured children. The study was performed in order to highlight the unique features of spinal injuries in children, and to assess the incidence and pattern of associated injuries. A total of 40 patients had a documented diagnosis of spinal injury. The charts and radiographs of all patients were retrieved and reviewed. The median age was 10 years (range 2-15) and 25 were male. The causative factors were motor vehicle accidents in 16, falls in 14, sport injuries in 7 and assaults in 3. Over 65% of the children sustained one or more associated injuries, the mean injury severity score was 18.95. There were two deaths, both in patients with severe multiple trauma and associated spinal fracture. Treatment included closed reduction in two patients and posterior open reduction and stabilisation in two patients, with one of these also requiring decompression. Spinal injuries in children differ from adults due primarily to the biomechanical and anatomical features of the developing musculoskeletal system. When a spinal injury is identified on initial radiographic or clinical evaluation of an injured child, one should have a high index of suspicion that concurrent, potentially life-threatening injuries may be present.

Accidental Falls↗
PubMed2003

The role of selectins in inflammation and disease.

Selectins are carbohydrate-binding molecules that bind to fucosylated and sialylated glycoprotein ligands, and are found on endothelial cells, leukocytes and platelets. They are involved in trafficking of cells of the innate immune system, T lymphocytes and platelets. An absence of selectins or selectin ligands has serious consequences in mice or humans, leading to recurrent bacterial infections and persistent disease. Selectins are involved in constitutive lymphocyte homing, and in chronic and acute inflammation processes, including post-ischemic inflammation in muscle, kidney and heart, skin inflammation, atherosclerosis, glomerulonephritis and lupus erythematosus. Selectin-neutralizing monoclonal antibodies, recombinant soluble P-selectin glycoprotein ligand 1 and small-molecule inhibitors of selectins have been tested in clinical trials on patients with multiple trauma, cardiac indications and pediatric asthma, respectively. Anti-selectin antibodies have also been successfully used in preclinical models to deliver imaging contrast agents and therapeutics to sites of inflammation. Further improvements in the efficiency, availability, specificity and pharmacokinetics of selectin inhibitors, and specialized application routes and schedules, hold promise for therapeutic indications.

Amino Acid Sequence↗
PubMedDate not supplied

Open reduction internal fixation after displacement of a previously nondisplaced acromial fracture in a multiply injured patient: case report and review of literature.

SUMMARY: A twenty-eight-year-old multiple trauma patient had a nondisplaced acromion fracture that was not detected until after it had displaced. Open reduction internal fixation was performed without complication and the patient achieved excellent shoulder abduction strength. Nondisplaced acromion fractures may displace if not protected. Open reduction internal fixation of displaced acromion fractures should be considered if deltoid muscle strength is important to the patient.

Acetabulum↗
PubMed1991

Traumatic atlanto-occipital dislocation in children: review and report of five cases.

Traumatic atlanto-occipital dislocation has usually been considered incompatible with life. However, reports on survivors stress the need for early clinical diagnosis of this condition, particularly in the context of multiple trauma, in order to avoid life-threatening diagnostic manipulations and to provide adequate treatment. Five instances of atlanto-occipital dislocation in children observed during the last two years prompted this report, since four of them survived only temporarily. The radiologic and computed tomographic (CT) findings have been reevaluated. Use of metrizamide CT is advised in clinically suspected cases with inconclusive radiologic workup.

Atlanto-Occipital Joint↗
PubMed2005

The importance of major extracranial injuries by the decompressive craniectomy in severe head injuries.

Neurosurgical therapy aims to minimise the secondary brain damage after a severe head injury. This includes the evacuation of an intracranial space occupying bleeding, the reduction of intracranial volumes, in hematocephalus an external ventricular drainage, and the conservative therapy in order to influence an increased intracranial pressure (ICP) and a decreased p(ti)02. When conservative treatment fails to act a decompressive craniectomy might be successful in lowering ICP. From September 1997 until July 2004 we operated on 737 patients with severe head injuries. 103 patients (14%) were treated by means of a decompressive craniectomy. The prognosis after decompression depends on the clinical signs and symptoms on admission, the patients age and the existence of major extracranial injuries. Our guidelines for an indication for decompressive craniectomy after failure of conservative interventions and evacuation of space occupying hematomas include a patients age below 50 years without multiple trauma, a patients age below 30 years in the presence of major extracranial injuries, a severe brain swelling on CT scan, the exclusion of a primary brainstem lesion or injury and the intervention before irreversible brainstem damage and secondarily while monitoring ICP and p(ti)02 in an interval up to 48 hours after the accident before irreversible brainstem damage or generalised brain damage has occurred.

Adult↗
PubMed1998

Two-trocar technique for terminal sigmoid colostomy in a patient with complex pelvic fracture.

We report a multiple trauma case with complex pelvic fractures and perineal wounds. The patient had a laparoscopic abdominal exploration with a simultaneous laparoscopic colostomy using the same wounds. Only two trocars were needed to perform both procedures. The technique is detailed here. The procedures were performed in less than an hour, with excellent postoperative recovery, achieving complete diversion of the rectal fecal contents.

Accidents, Traffic↗
PubMed2006

Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy.

PURPOSE OF THE STUDY: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions. A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach. The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis. Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.

Accidents, Traffic↗