Injury
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The evaluation of thoracic injuries is only one aspect of the total assessment of a severely injured patient. In a series of 675 hospitalized patients, blunt chest injury was associated with craniocerebral injury in 55 per cent, with abdominal injuries in 20 per cent and with fractures of the extremities in 38 per cent. Both diagnostic and therapeutic procedures go hand in hand. ⋯ Most blunt thoracic injuries can be treated adequately by intercostal tube drainage. Operative intervention has been found necessary in 8 per cent of cases. Indications for thoracotomy are clearly defined.
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The appropriate intravenous therapy for injured patients is controversial. Use of colloid-containing solutions has been advocated in an attempt to maintain intravascular colloid osmotic pressure, minimize pulmonary oedema and draw fluid out of areas of contused lung. Studies of animals with lymph fistulas in the lung do not support such therapy and there is no difference between lung water volumes in animals resuscitated for 3 hours with colloid as opposed to crystalloid solutions after a standardized traumatic insult (colloid = 8.4 + 0.8 ml/kg; crystalloid = 7.5 + 0.6 ml/kg). ⋯ Low plasma colloid osmotic pressures do not correlate with increases in extravascular lung water. A shift to the use of vigorous crystalloid resuscitation of injured patients at our institution has resulted in decreases in both mortality rate (1976-1979, 35 per cent; 1979-1981, 28 per cent) and the rate of dialysis-dependent renal failure (1976-1979, 6 per cent; 1979-1981, 2 per cent). Current evidence supports the use of crystalloid solutions together with blood for resuscitation after injury.
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While penetrating wounds of the thorax are rather uncommon in The Netherlands, they are frequently encountered in the emergency centres of the United States. Thoracic wall penetration may occur during times of warfare, during social altercations or as a result of industrial accidents. ⋯ Pre-hospital intravenous fluids, pleural decompression and anti-shock garments are contraindicated. On arrival in the emergency room, establishment of a patent airway, administration of intravenous fluids, pleural decompression and early X-ray examination of the chest are mandatory.
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The treatment of flail chest remains highly controversial. In the literature convincing arguments can be found to support any therapeutic procedure. Newer concepts of mechanical ventilation such as SIMV and CPAP, as well as the use of epidural analgesia, have resulted in a significant reduction in the duration of artificial ventilation. ⋯ A ratio of CPK-MB: total CPK of over 6 per cent provides a very significant suspicion of myocardial contusion. The clinical course is characterized by cardiac rhythm disturbances, which required treatment in 40 out of 108 patients, and to a minor extent by heart failure for which treatment was required in 17 patients. Prognosis is generally good with adequate treatment.