Der Unfallchirurg
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The initial management of patients with multiple trauma requires a well-defined plan of action for immediate and adequate therapy, that ensures fast recognition of life-threatening conditions and injuries. While treatment protocols for specific situations and injuries are fairly well defined, there are few such concepts for the overall management process. Therefore, we designed a comprehensive algorithm for in-hospital trauma care to give priority-based guidelines to the trauma room physician. ⋯ The first algorithm starts with the initial assessment of immediate life-threatening disorders of A (airways), B (breathing) and C (circulation) and is followed by the early stabilization and maintenance of vital functions. It is followed by six interrelated flow charts, based on disturbed physiological functions (respiration, circulation) and anatomical injuries (thorax, abdomen, head/brain, spine/pelvic girdle/extremities), which are worked up simultaneously and repeatedly. This algorithm is not only intended as an overall guideline for use the management of severely injured patients, but is also indispensable for quality assurance.
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The chondromyxoid fibroma as a benign bone tumour is described. The difficult but extremely important differential diagnosis from chondrosarcoma is discussed, and the question of the existence of malignant chondromyxoid fibroma is examined. ⋯ Experience with seven chondromyxoid fibromas and two tumours misdiagnosed as malignant chondromyxoid fibromas are described. In view of the clear definition of chondromyxoid fibroma and chondrosarcoma the term malignant chondromyxoid fibroma is not justified and should no longer be used.
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A prospective study of 135 secondary operations (> 24 h after trauma) in patients with multiple injuries (ISS 40.6 pts) was performed to determine specific and unspecific indicators of the inflammatory response that may indicate the degree of risk of postoperative organ failure in these patients. On the morning of the operation each patients' data were recorded and blood samples were collected. Patients were divided in those in whom respiratory, renal and/or hepatic failure developed or preexisting organ failure worsened by more than 20% from baseline within 2 days after the operation and those who had no complications. ⋯ In 106 patients with secondary operations later than 72 h after trauma, neutrophil elastase, C-reactive protein and platelet count revealed the highest predictive accuracy, with cut-off values of 250 ng/ml, 11 mg/dl and 180 x 10(6)/ml, respectively. The combined accuracy of these three parameters in prediction of postoperative organ failure was 79% (sensitivity 73%, specificity 83%). In this group of patients the pO2/FiO2 ratio was of less value and blood pressure, heart rate, renal function parameters, lactate and coagulation parameters were of no value.(ABSTRACT TRUNCATED AT 250 WORDS)
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There are several scores available for assessment of disability and handicap in rehabilitation. In primary treatment most interest has so far been given to the assessment of neurological recovery after operative decompression of the spinal cord. ⋯ Scores should take account of this. The neurological classification of ASIA, IMSOP and DMGP seems to be suitable for assessment of the course through-out the rehabilitation period.
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Among the more than 50 scoring systems available for quantitative evaluation of injury severity, only a few have proved effective in clinical practice. In particular, the Revised Trauma Score (RTS), referring to physiological variables, has proved effective in preclinical use and otherwise, the Injury Severity Score (ISS), referring to anatomical data. There is a tendency in the development of new scoring systems to aim at higher predictive accuracy, forfeiting practicability. ⋯ When the scoring systems currently available are applied their specific deficiencies and limited evidence must be borne in mind. Nevertheless, they are an important scientific instrument for comparative examinations, and indispensable for quality assurance and economic analyses. To improve the predictive accuracy, biochemical parameters and chronic diseases should be considered, in addition to existing scores.