Injury
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While penetrating wounds of the thorax are rather uncommon in The Netherlands, they are frequently encountered in the emergency centres of the United States. Thoracic wall penetration may occur during times of warfare, during social altercations or as a result of industrial accidents. ⋯ Pre-hospital intravenous fluids, pleural decompression and anti-shock garments are contraindicated. On arrival in the emergency room, establishment of a patent airway, administration of intravenous fluids, pleural decompression and early X-ray examination of the chest are mandatory.
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The treatment of flail chest remains highly controversial. In the literature convincing arguments can be found to support any therapeutic procedure. Newer concepts of mechanical ventilation such as SIMV and CPAP, as well as the use of epidural analgesia, have resulted in a significant reduction in the duration of artificial ventilation. ⋯ A ratio of CPK-MB: total CPK of over 6 per cent provides a very significant suspicion of myocardial contusion. The clinical course is characterized by cardiac rhythm disturbances, which required treatment in 40 out of 108 patients, and to a minor extent by heart failure for which treatment was required in 17 patients. Prognosis is generally good with adequate treatment.
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The evaluation of thoracic injuries is only one aspect of the total assessment of a severely injured patient. In a series of 675 hospitalized patients, blunt chest injury was associated with craniocerebral injury in 55 per cent, with abdominal injuries in 20 per cent and with fractures of the extremities in 38 per cent. Both diagnostic and therapeutic procedures go hand in hand. ⋯ Most blunt thoracic injuries can be treated adequately by intercostal tube drainage. Operative intervention has been found necessary in 8 per cent of cases. Indications for thoracotomy are clearly defined.
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Clinical Trial Controlled Clinical Trial
Use of sterile gloves in the management of sutured hand wounds in the A&E department.
In a single-blind, controlled, prospective trial of 242 sutured wounds of the hand in the A&E department there was increased late purulent infection in those treated without gloves. This difference is statistically significant. We recommend wearing of sterile gloves to suture all wounds in A&E departments.