European journal of emergency medicine : official journal of the European Society for Emergency Medicine
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Comparative Study Clinical Trial
Early intubation in severely injured patients.
In a prospectively studied trauma population from 1986 to 1991 the influence of early intubation (EI) 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 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and the severity of injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 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 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 EI group. We conclude that EI 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.
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Comparative Study
Prehospital detection of uncontrolled haemorrhage in blunt trauma.
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. ⋯ Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. 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.
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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. ⋯ 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.
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Clinical Trial
Haemodynamic evaluation during small volume resuscitation in patients with acute respiratory failure.
In addition to the invasive haemodynamic monitoring procedures, an on-line assessment 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 Syndrome (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 l-1; Leopold, Graz; Austria] combined with NaCl [75 g l-1) on haemodynamics and cardiac performance using the transoesophageal echocardiography. After institutional approval we investigated 23 patients suffering from septic ARDS after trauma or major surgery during four periods of resuscitation. ⋯ 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 adequate preload and oxygen delivery in patients with sepsis-related acute respiratory failure.