Zentralblatt für Chirurgie
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Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries because diaphragmatic injury does not play an important role beside severe injuries of intrabdominal and/or thoracic organs. Between 1976 and 1993, 141 patients were treated for traumatic injury of the diaphragm. In 42 patients with penetrating injuries following stab or shot wounds diaphragmatic lesions were diagnosed by the emergent surgical therapy. 99 had diaphragmatic tears from blunt thoracic or abdominal trauma by accidents. 14 of 99 patients sustained isolated diaphragmatic rupture, in 85 the rupture was combined with other injuries, 24 had fractures of the pelvic ring. ⋯ Therapy of diaphragmatic injury was performed in 83 patients within 4 days, in 9 within 4 months and in 7 later than one year. For diaphragmatic repair 87 patients underwent laparotomy and 12 thoracotomy. Local complications were found in 13 patients (13.1%). 19 patients (19.2%) died postoperatively due to accompanying injuries.
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Review Comparative Study
[Value of clinical scoring systems for evaluation of injury severity and as an instrument for quality management of severely injured patients].
Trauma Score Systems attempt to summarize the severity of injury in a single value. They provide a better classification of trauma patients and translate different severities of injury in a common language. They enable thereby comparisons between hospitals or trauma systems. ⋯ Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score and TRISS are the most often used international scores for severely injured patients. Their sensitivity and specificity, validity, reliability and practicability have been studied and proved in many trials. The role of these scoring systems for quality management purposes in the treatment of severe trauma is actually studied with the Trauma Registry of the German Society for Trauma Surgery.
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Adequate prehospital care of the severely traumatised patient is important to prevent or attenuate early as well as late life threatening complications, such as tissue hypoxia, ischemia/reperfusion injury and finally multiple organ failure. A mismatch of oxygen supply and oxygen demand is a hallmark in the pathophysiology of multiple trauma. Oxygen supply may be diminished by the following factors: shock-related decrease of cardiac output, anemia and hypoxia. ⋯ Furthermore, ventilatory support is indicated when respiratory failure, loss of consciousness, or severe shock are present. Additional oxygen should be given whenever possible, even in the absence of an overt hypoxic state. Important additional measures are cervical spine immobilisation and reposition as well as splinting of long bone fractures or luxations, in order to avoid secondary injury of the spinal cord or ongoing tissue and vascular damage.
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Multiple trauma often leads to systemic inflammatory reaction and multiple organ dysfunction. Modulation of this response may be promising. ⋯ Hence, supportive care of failing organs, treatment of hypoxemia and maintenance of an appropriate systemic blood pressure remain the mainstay of critical care therapy. Widely accepted therapeutic measures are (i) immediate treatment of hypoxia by administration of oxygen and ventilatory support, if needed, to maintain an oxygen tension of 60 mmHg or higher (ii) maintenance of adequate oxygen content by transfusion of red packed cells in order to restore a hematocrit of 23-30% (iii) treatment of hypovolemia by infusion of crystalloids, colloids and blood products (iv) normoventilation and restoration of a normal or elevated blood pressure in patients with severe head injury (v) immobilisation and early administration of methylprednisolone in patients with spinal cord injury (vi) analgesia by administration of opioids, non-steroidal antiinflammatory drugs, or ketamine (vii) sedation with benzodiazepines, gamma-hydroxbutyrate or propofol (viii) early enteral nutrition (ix); antibiotic therapy of infections (x) pressure controlled ventilation in patients with acute lung injury (xi) continuous veno-venous hemofiltration in patients developing acute renal failure and (xii) early surgical interventions to control bleeding and/or to evacuate intracerebral hematomas.
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Review
[Does multi-vessel disease of brain supplying arteries modify the procedure in carotid operations?].
In a prospective evaluation 159 patients with carotid artery stenosis showed a multiple artery disease in 78 to 99% depending on the grade of cerebral artery insufficiency. Contralateral occlusion process could be detected in 15.7%, internal and common carotid artery occlusion in 16 patients (10%). 1595 patients picked out of the literature have been analyzed in respect of the natural history which showed a risk to develop a stroke in 4.5%/year. In further 1286 operated patients of other reports the morbidity and mortality rate ranged 4.5% and the risk of further neurologic events after operation was 2.4%/year. The use of an intraluminal shunt after thrombendarterectomy proved to be a good procedure to lower the morbidity and mortality rate without any intraoperative monitoring.