Der Unfallchirurg
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In medical services where acute accident patients are encountered, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the Department of Surgery at the University Hospital in Munich, we have been performing neurotraumatological treatment since 1983. We had 162 patients with severe head and brain injuries, 95 intracerebral contusional bleeding, 8 depression fractures, and 3 hygromas. ⋯ Comparison with other investigations in departments of neurosurgical surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1 cured; 2 slightly; 3 severely handicapped; 4 vegetative state; 5 expired). The Traumatic Coma Data Bank (1991) recorded the outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.
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We report the cases of two patients who last lims as a result of heparin-induced thrombocytopenia (HIT). On the basis of these cases, the incidence, pathophysiology and the diagnosis of HIT are reviewed. ⋯ For HIT prophylaxis and treatment of thromboembolic complications is recommended Orgaran. Exact dosage schedules are provided.
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The elbow joint often reacts to different injury patterns of the intra- and extra-articular structures with uniform symptoms that can hardly be differentiated. Furthermore, several neural entrapment syndromes around the elbow should be taken into consideration, because they make the differential diagnosis even more difficult. ⋯ Besides the static and dynamic examination and specific stability tests, the symptoms of relevant neural compression syndromes are checked. This physical examination program represents a guideline for the systematic evaluation of the anatomical and morphological structures that are responsible for the individual symptoms.
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Both prehospital and hospital management of patients with severe head injury has clearly improved in the last decades. There is a greater knowledge of how secondary brain injury is caused and how it can be prevented. Intracranial mechanisms (e.g. haematoma and elevated intracranial pressure and systemic mechanism (e.g. shock and hypoxaemia) are two of the major causes of secondary brain injury. ⋯ The neck of the patient should be positioned straight and the upper part of the body should be elevated to about 30 degrees. The prophylactic use of steroids, mannitol or high dose barbiturates is not indicated. Aggressive hyperventilation (pCO2 < 30 mmHg), especially during the first few days after severe brain injury, should be avoided.