British medical bulletin
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In the UK, emergency ambulances are responding to astonishing increases in levels of emergency calls, in the order of a 40% increase nationally in the last 5 years. Pressures in primary care service out-of-hours provision, and increasing community-based care of elderly patients, as well as increased expectation by the public are contributory causes. Services are also being pressed to improve response times, particularly to life-threatening cases. These various aspects are discussed below.
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The majority of patients with polytrauma seen in the UK are victims of blunt injury. The trauma reception team approach, using a predetermined plan for initial assessment and urgent resuscitation, can improve outcome. It is important, therefore, that each member of the team is familiar with both their own role and that of their colleagues. ⋯ Accurate assessment of shock in the victim of trauma is difficult, as the simple clinical indicators are not ideal. Some of the techniques available for advanced assessment of tissue perfusion are discussed in detail. The management of polytrauma provides a considerable clinical challenge, and this chapter emphasises the importance of a team approach.
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Optimising the results of fracture treatment requires a holistic view of both patients and treatment. The nature of the patient determines the priority targets for outcome, which differ widely between the elderly and the young, and between the victims of high and low energy trauma. The efficacy of treatment depends on the overall process of care and rehabilitation as well as the strategy adopted to achieve bone healing. ⋯ The development of systems for early fracture stabilisation has been an advance. However, narrow thinking centred only on the restoration of mechanical integrity leads to poor strategy--the aim is to optimise the environment for bone healing. Future advances may come from the adjuvant use of molecular stimuli to bone regeneration.
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Appropriate fluid replacement is an essential component of trauma patient resuscitation. Once haemorrhage is controlled, the restoration of normovolaemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid resuscitation may be harmful. ⋯ A number of haemoglobin solutions are under development but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the mean time, contrary to traditional teaching, recent data suggest that a restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.
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Inter-individual variability in drug response is a major clinical problem. Adverse drug reactions (ADRs) are common, are responsible for a number of debilitating side effects following drug therapy and are a significant cause of death. It is now clear that much of the observed variability in drug response has a genetic basis, arising as a result of genetically-determined differences in drug absorption, disposition, metabolism or excretion. ⋯ Individuals at risk of developing ADRs as a result of genetically-determined variation in genes such as CYP2D6 can now be identified using DNA-based tests. A detailed knowledge of the genetic basis of individual drug response is potentially of major clinical and economic importance and could provide the basis for a rational approach to drug prescription. This would have significant benefits for human health.