Zentralblatt für Chirurgie
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The treatment and outcome of the respiratory failure decisively depend on its pathophysiological background. Besides simple blood gas analysis the investigation of the respiratory mechanics, interstitial lung water and the monitoring of the pulmonary pressure are necessary for an exact diagnosis. As a scoring method of lung failure the classification by Murray and Morell is most common. ⋯ New methods as negative pressure ventilation, extracorporeal lung ventilation and liquid or partial liquid ventilation are not common yet and should be used only under special conditions. As a supplement of these modes of ventilation the application of prostacyclins, nitric oxide, surfactant and inhibitors of the arachidonic pathway is under clinical investigation. A limitation of the treatment of lung failure should be considered in irreversible multiple organ failure.
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Pulmonary embolism is a major cause of postoperative problems, accounting for 12-20% postoperative deaths. 0.1% to 0.4% of all hospitalised patients die due to acute pulmonary embolism. Thus, pulmonary embolism should be included in the differential diagnostic considerations. Blood gas analysis, ECG, chest roentgenography, scintigraphy, pulmonary arterial catheterisation, echocardiography, digital subtraction angiography, and angiography are important diagnostic tools. ⋯ A neurosurgical operation in the preceding 10 days is still considered an absolute contraindication to thrombolysis. Patient outcome in the case of cardiopulmonary resuscitation for massive pulmonary embolism may be improved by the bolus application of 2-3,000,000 U of urokinase. In addition or alternatively, mechanical thrombus fragmentation via catheter or surgical embolectomy may be used in certain hospitals.
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Emergency medicine is subjected worldwide to financial stringencies and organizational evaluations of cost-effectiveness. The various links in the chain of survival are affected differently. Bystander assistance or bystander CPR is available in only 30% of the emergencies, response intervals--if at all required by legislation--are observed to only a limited degree or are too extended for survival in cardiac arrest. ⋯ Efficiency of emergency physician activities can be demonstrated in polytraumatized patients or in patients with ventricular fibrillation or acute myocardial infarction, in patients with acute myocardial insufficiency and other emergency clinical pictures. Cost effectiveness is clearly in favor of emergency medicine. Future developments will be characterized by the consequences of new health care legislation and by effects of financial stringencies on the emergency medical services.
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Polytraumatized patients develop complex changes in blood coagulation and fibrinolysis even before their arrival at the emergency room (ER). Hemostaseological parameters (i.e. antithrombine 3, alpha-2-antiplasmine, D-dimers) obtained upon admission however, permit advance differentiation of later mortality vs. survival and of possible future secondary organ failure with varying specification. ⋯ In our study patients with multiple injuries displaying a systolic blood pressure of less than 100 mmHg either at the scene of the accident or upon arrival in the ER showed coagulation values which by other investigators were regarded as a sign of potential secondary organ failure or death.
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Microcirculatory disturbances and increased adhesion of leukocytes to the hepatic endothelium immediately following hemorrhagic shock have been observed. It is currently discussed, that mediators released by activated macrophages may have regulative functions for these alterations. The aim of the study performed was to investigate the effects of platelet activating factor (PAF) by application of PAF-receptor antagonists in respect to disorders of liver microcirculation and leukocyte adhesion following hemorrhagic shock. ⋯ Liver microcirculation following adequately treated hemorrhagic shock was disturbed, as indicated by narrowed sinusoids and increased adhesion of leukocytes. PAF seems to have no effect on sinusoidal narrowing in this period, however, it seems involved in temporary adhesion of leukocytes. The relevance of these early changes following hemorrhagic shock in respect to the development of organ dysfunction should be further addressed.