Der Anaesthesist
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The preclinical tension pneumothorax which even without technical support is easily recognizable, requires immediate decompression. However, there are a number of patients with thoracic injuries such as serial rib fractures or palpable skin emphysema which--in combination with a ventilator--may necessitate the insertion of a thoracic tube. In the preclinical setting this procedure usually only takes place in the ventilated patient. With patients who are respiratorily compensated and are breathing spontaneously, careful control and a conservative approach is advised even if pneumothorax is suspected.
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Even 30 years after its first publication the Glasgow Coma Scale (GCS) is still used worldwide to describe and assess coma. The GCS consists of three components, the ocular, motor and verbal response to standardized stimulation, and is used as a severity of illness indicator for coma of various origins. The GCS facilitates information transfer and monitoring changes in coma. ⋯ Its prognostic value regarding the outcome after a traumatic brain injury still lacks evidence. One of the main problems is the evaluation of the GCS in sedated, paralysed and/or intubated patients. A multitude of pseudoscores exists but a universal definition has yet to be defined.
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The future of shock treatment depends on the importance of scientific results, and the willingness of physicians to optimize, and to reconsider established treatment protocols. There are four major potentially promising approaches to advanced trauma life support. First, control of hemorrhage by administration of local hemostatic agents, and a better, target-controlled management of the coagulation system. ⋯ Third, pharmacologic support of physiologic, endogenous mechanisms involved in the compensation phase of shock, and blockade of pathomechanisms that are known to cause irreversible vasoplegia (arginine vasopressin and K(ATP) channel blockers for hemodynamic stabilization). Fourth, employing potentially protective strategies such as mild or moderate hypothermia. Finally, the ultimate vision of trauma resuscitation is the concept of "suspended animation" as a form of delayed resuscitation after protection of vital organ systems.
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Internal transfer pricing system (ITPS) of anaesthesia services is established to guarantee a close connection of delivered service and the budget of the department of anaesthesia. In most cases a time-based system is used with the pricing unit being calculated as the quotient from the enumerator "costs" divided by the denominator "anaesthesia time in minutes". The implementation of a transfer pricing system requires the identification of all relevant costs caused by the department of anaesthesia and a cost centre structure is needed which allocates all costs correctly according to their cause. ⋯ To generate valid data not only the necessary technical infrastructure is needed, but also detailed training of the staff and plausibility checks are needed to ensure correct and complete data. Subsequent agreements with the hospital administration are necessary in order to adjust the system if extrinsic cost increases occur. This paper gives a step-by-step guidance for the successful implementation of an internal transfer pricing system based on anaesthesia time.
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We aimed to explore current practices in use of therapeutic hypothermia after traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) in intensive care of adults. ⋯ Therapeutic hypothermia is used in 39% after TBI and 18% after SAH in the intensive care of German anaesthesia departments. There is no standard in management, and there is wide variation in practices of duration of cooling and rewarming. For patients' benefit, evidence-based recommendations on therapeutic hypothermia should be published by the appropriate medical societies in the German language.