摘要:

In a prospectively studied trauma population from 1986 to 1991 the influence of early intubation (El) within 2 h after the accident on post-traumatic (multiple) organ failure (M)OF was compared with delayed intubation (DI) in 131 patients with multiple injuries (Injury severity score (ISS) 37). Indications for intubation were unconsciousness following severe head injury in 45 cases (45 El, 0 DI), major chest trauma (AIS>3) in 40 (31 El, 9 DI) and the severity of injuries (no head or chest trauma, but ISS>24) in 40 patients (30 El, 10 DI). One hundred and six trauma victims (81%) have been intubated early and 19 patients (14.5%) required intubation and artificial ventilation later in the course, whereas 6 subjects (4.5%) could manage spontaneous breathing. The pattern of injured body regions and respiratory parameters on admission showed no remarkable difference in the two groups, but the severity of injury was significantly higher (p<0.001) in the El group (ISS 39) compared with the DI patients (ISS 29). Due to a significantly worse haemodynamic condition of the El patients on admission, they showed significantly higher volume requirements throughout the resuscitation period. All patients were treated to a standard resuscitation protocol. Sixty-seven per cent of the El patients developed at least one OF, 45% respiratory failure (RF), 28% multiple organ failure (MOF) and 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%) and an even higher (n.s.) incidence of MOF (37%) and mortality rate (26%). Corresponding to the significantly lower injury severity of the DI group, the observed OF and mortality rates are inappropriately high in comparison with the incidence of OF and death in the El group. We conclude that El of multiple injured patients within 2 h after trauma along with ventilatory support - even in alert patients without major chest trauma or signs of cardiocirculatory or respiratory insufficiency, but a known or suspected ISS>24 - may help to reduce post-traumatic organ failure and improve outcome.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

It is estimated that 1.4 million patients each year attend Accident and Emergency (A&E) departments in the UK with a head injury. The vast majority are, in retrospect, diagnosed as a 'mild' injury. There is evidence to suggest that many develop short term morbidity and some long term problems. The incidence is unknown. Early recognition and treatment may hasten recovery. A national postal survey of A&E departments revealed a general unawareness for this morbidity. Written advice given to patients on discharge from the departments was exclusively concerned with the symptoms expected if serious complications developed. A description of the common symptoms of fatigue, poor memory and concentration were not given to the patients in a written format. Arrangements for follow up are, in the majority of hospitals, unstructured. We recommend a positive approach to the management and follow up of mild head injury. This should recognize the common problems experienced by these patients and cater for their needs. More interest and research is required into this aspect of head injury.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n=353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et ah, 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

In addition to the invasive haemodynamic monitoring procedures, an on-line assessement of cardiac performance by means of transoesophageal echocardiography might have a certain role in small volume resuscitation of patients with acute respiratory failure or Adult Respiratory Distress Syndome (ARDS). The goal of this investigation was therefore to determine the effects of a hypertonic hyperoncotic solution, hypertonic hydoxyethl-starch (HHES), (HHES=HES [200.000/0.6-0.66; 60 g I-1; Leopold, Graz; Austria] combined with NaCl [75 g I-1) on haemodynamics and cardiac performance using the transoesophageal hocardiography. After institutional approval we investigated 23 patients suffering from septic ARDS after trauma or major surgery during four periods of resuscitation. Phase I=control values after infusion of 20 ml kg-1crystalloid solution, phase II=50% hypertonic hydroxyethyl-starch solution (2 ml kg-1), phase III=at the end of HHES (4 ml kg-1), IV=30 min after the end of HHES. Before HHES-infusion, all patients showed arterial hypotension with mean arterial pressures of 64±2 mmHg. The infusion of 2 ml kg-1HHES resulted in a significant increase of systemic and pulmonary arterial pressures over the study period. A significant improvement in cardiac output was associated with increasing stroke volumes, oxygen delivery and oxygen consumption (see Tables 1 and 2). Small volume resuscitation also resulted in significant increases of endsystolic and endiastolic left ventricular areas and the corresponding calculated wall stress (Figs 1-3). We conclude from our preliminary data that when using HHES, only modest fluid resuscitation was sufficient to restore adaequate preload and oxygen delivery in patients with sepsis-related acute respiratory failure.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Failure to recognise the importance of the dispatch centre in emergency medical services (EMS) limits standards and procedures in prehospital emergency medicine. The dispatch centre should be identified as the point of leadership and management of the entire system. Measures for quality control and quality assurance should be an integral part of EMS administration. Minimum requirements for equipment and personnel depend on EMS structure and on geographic and epidemiological factors. Clearly defined algorithms for decision-making and computer-assisted dispatching can increase efficiency and reduce costs.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Despite several large studies, the scoop and run versus field stabilization debate in prehospital trauma care continues. It is unlikely that all trauma patients are best treated by either field stabilization or scoop and run and the most effective form of prehospital care may be dependent upon the type of injuries sustained. Studies suggest that penetrating trauma involving major vascular injury may be best treated by scoop and run since advanced life support (ALS) measures serve only to delay time to definitive surgical treatment. Conversely, patients with head injuries may benefit from rapid ALS performed on scene in order to control airway and breathing problems, and reduce intracranial pressure prior to transport. Between these two groups of patients lie those with blunt trauma in whom scoop and run may be most appropriate if there is major vascular damage or those in whom field stabilization may offer the patient a greater chance of survival if blood loss is not a life-threatening problem.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

We report a case of profound accidental hypothermia with asystolic cardiac arrest which was reversed after 5.5 hours of mechanical cardio-pulmonary resuscitation. Rewarming was achieved by the use of partial cardio-pulmonary bypass.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

We report the case of a 23-year-old male who presented to the emergency department with severe upper airway obstruction resulting from infection of the palatine tonsils. Manifestations of tonsillar infection and airway obstruction included hoarseness and extreme difficulty breathing, severe sore throat and inability to swallow liquids or solids. Urgent otolaryngologic consultation was obtained, and the patient was taken directly to the operating suite for nasotracheal intubation with tracheostomy standby. The patient was maintained on broadspectrum antibiotics and was discharged after a hospital course complicated by pulmonary oedema, tracheitis and difficulty weaning from the ventilator, requiring temporary tracheostomy. The Monospot test was negative for infection with the Epstein-Barr virus (EBV). We could find no previously reported cases of adults with severe palatine tonsillar-induced airway obstruction which was not due to infection with EBV (mononucleosis). The airway management of obstruction due to palatine tonsillar hypertrophy is discussed.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Health care workers in emergency departments are at particular high risk for acquiring occupational bloodborne infections. Needle stick injuries are the main hazard. Systematic HIV testing of patients admitted to emergency department is not a cost beneficial way to protect health care workers from acquiring such infections. Prevention strategies should be based on the adherence to universal precautions, hepatitis B vaccination, the utilization of safer devices and the training/education of health care workers.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

The first step in the accurate diagnosis of infectious diseases is to provide the laboratory with adequate specimens for microbiological examination. The sample must be representative of the disease process: samples collected on body surfaces, harbouring saprophytic germ are less reliable than aspiration of closed body areas. A sufficient quantity of infectious material, preferably sampled with a syringe aspiration than with a swab, must be transported rapidly to the laboratory. Finally, close collaboration between the clinician and the microbiologist is essential for appropriate collection of selected specimens and corrected interpretation of the bacteriological results. Gram-stained smear examination of the samples is extremely useful and can provide immediate information for initiation of rational empiric antibiotic treatment. The indications for blood cultures sampling are reviewed. Number of blood cultures and volume of blood per culture are important. Screening of the sputum to discard samples too contaminated by the saliva is mandatory: if only screened samples are considered, a sputum Gram stain is a reliable guide to empiric therapy. Gram stain is also essential in the examination of the cerebrospinal fluid as well as is the detection of bacterial antigens. Cytological and chemical characteristics of this exudate are useful in differentiating bacterial meningitis from other diseases but there is considerable overlap between the laboratory parameters of bacterial meningitis and infections of other etiologies.

ISSN:0969-9546    

出版商:OVID    

年代:1994

数据来源: OVID