Zentralblatt für Chirurgie
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Diagnostic and therapeutic measures after severe head-injury in the intensive care unit are discussed. The main goal of all efforts consists in minimizing secondary brain damage. Adequate shock therapy in the initial phase proves crucial for the later outcome. ⋯ Surgical and conservative modalities of therapy are further examined. Controversial methods (barbiturates, steroids, some osmotic active agents) as well as new concepts of therapy are also included. The clinician is provided with a critical discussion of the value of the different methods from our point of experience.
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Patient-controlled analgesia (PCA) is a newer technique for pain management. Patients are allowed to self-administer small analgesic bolus doses, which have been preprogrammed by the physician, into a running intravenous infusion, intramuscularly, subcutaneously or even into the epidural space. Patients' demands are mostly controlled by computer-driven infusion pumps, but can also be delivered by simple disposable devices. ⋯ It is suggested that PCA results should be used for the improvement of conventional techniques. PCA has also been found valuable for scientific pain studies, e.g. to determine predictors of postoperative pain, drug interactions and pharmacokinetic experiments. This review concentrates on intravenous PCA during the early postoperative period.
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Open pelvic fractures are rare fractures usually resulting from a severe trauma. Only 4 of 121 patients treated operatively in 1994 for a pelvic trauma showed an open injury. ⋯ The presented concept comprises in the end the hemipelvectomy and an intensive care management for prophylaxis of septic complications. So the lethality was diminished.
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Until the early eighties conservative treatment was common even for unstable pelvic fractures. The long-term results of 114 non-operatively treated patients who had suffered a pelvic fracture (68 type A, 20 type B, 26 type C according to the classification of the ASIF) have been examined after an average time of 7.1 years after injury. 60% of cases with a stable injury of the pelvis (type A) did not suffer of any complaint. The remaining patients stated moderate pain. ⋯ Patients with unstable pelvic fracture localized pain mainly in the lumbo- or iliosacral region. Radiological and CT findings suggest arthrosis, partial ancylosis and incomplete reduction of the fracture as possible reasons for unsatisfactory clinical results. As consequence of these results we nowadays proceed extended radiological examinations (a.-p.-, inlet-, outlet-views, CT) and operative reduction and internal stabilization (ORIF) of all unstable pelvic fractures.