Der Unfallchirurg
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Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35 degrees C, already at admission in the emergency room. As a drop of the core temperature below 34 degrees C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. ⋯ Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.
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Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. ⋯ However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.
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Review
[Surviving multiple trauma--what comes next? The rehabilitation of seriously injured patients].
The survival chances of multiple trauma patients have improved continuously over the last decades. Therefore, not only the question of whether the patient survives a serious accident arises, but rather how the patient survives it. The after effects of trauma are seen not only physically, but also psychologically and socially. ⋯ The International Classification of Functioning, Disability and Health (ICF) provides a system to classify the after effects of trauma, which can be measured with the help of assessment instruments. Knowing which parameters can influence trauma after effects is essential for the planning, organization, and implementation of a rehabilitation programme following severe injury. The requirements of an optimal rehabilitation process place high demands on the rehabilitation facility and on the rehabilitation team, which ultimately can only be fulfilled by specialized facilities.
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More than 25% of polytraumatized patients present in the emergency department with a coagulopathy which results in a 4-fold increase in mortality. The detection of microvascular bleeding is the major clinical indicator. Measurement of fibrinogen, activated partial thromboplastin time and prothrombin time as well as thrombelastometry are required. ⋯ A clear advantage for survival has not yet been shown and some of the risks include insufficient substitution of fibrinogen and transfusion-related acute lung injury. Goals for the administration of platelet concentrates depend on the acuity of bleeding, injury pattern (e.g. head trauma) and clinical signs of microvascular bleeding. Factor VIIa remains an off-label rescue therapy if bleeding persists despite optimization of preconditions and specific coagulation management.
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With the increasing use of minimally invasive plate osteosynthesis in the last years almost every anatomical region was included in this new technique. Thus, it is not used any more for certain fractures and problematic areas, but also in fractures where it represents a challenge to established osteosynthesis techniques like intramedullary nailing or conventional plating. ⋯ The most popular indications for the use of minimally invasive plate osteosynthesis are presented and the technical details are discussed. The possibilities for complications--in a common way and for specific fractures--are presented and discussed.