British medical bulletin
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Since the introduction of manual positive pressure ventilation during the Copenhagen polio epidemic of 1952, a range of mechanical devices and methods of ventilatory support have been developed to provide life-saving respiratory therapy to critically ill patients. In addition to the development of the equipment hardware to enable effective mechanical ventilation, there has been a gradual realisation that a single mode of ventilation is not universally applicable to all patients, individual pathologies, or to individual patients at various stages in the evolution of their pulmonary pathology. ⋯ This iatrogenic problem is known as ventilator induced lung injury and, although it may be a problem in any patient requiring mechanical ventilation for any reason, is of particular importance to those patients requiring mechanical ventilation as a consequence of trauma. This chapter describes the range of ventilatory support techniques available, the problem of ventilator induced lung injury with specific reference to trauma patients and offers a strategy for ventilatory support in the trauma patient.
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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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British medical bulletin · Jan 1999
ReviewThe role of the endothelium in modulating vascular control in sepsis and related conditions.
The majority of deaths amongst critically ill patients requiring intensive care are attributable to sepsis and its sequelae: septic shock, the systemic inflammatory response syndrome (SIRS) and the acute respiratory distress syndrome (ARDS). Patients within the ICU who develop these conditions and fail to survive succumb to multiple organ dysfunction syndrome (MODS). ARDS is considered to be the pulmonary component of MODS and is characterized by pulmonary hypertension, often in the setting of systemic hypotension. ⋯ Pro-thrombotic, pro-inflammatory and vasoactive mediators are released including nitric oxide (NO), endothelins (ETs) and products of cyclo-oxygenase metabolism. It is probably the disordered production of these mediators in vascular beds that results in MODS. This review highlights recent research in this area with particular emphasis on possible therapeutic options.
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British medical bulletin · Jan 1999
ReviewOptimal use of resources for the treatment and prevention of injuries.
Injuries are an important cause of mortality and morbidity. Although accidental injury rates have been declining throughout the twentieth century in the UK, this pattern has been variable. ⋯ Although there is little evidence that road traffic accident case fatality rates have been improving, there is some evidence that improvements in trauma care have been responsible for reducing injury death rates in children. Thus, although there have been considerable successes in the primary prevention of accidents, and the secondary prevention of injuries in accidents, there is an important role for tertiary prevention, that is in the prevention of avoidable outcomes through good trauma care.
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British medical bulletin · Jan 1999
ReviewCerebral protection in severe brain injury: physiological determinants of outcome and their optimisation.
The primary role of intensive care in acute head injury lies in the prevention, detection and reversal of secondary neuronal injury. The maintenance of optimal systemic and cerebrovascular physiology can substantially contribute to these aims. There is, however, a role for novel neuroprotective interventions, many of which are currently under investigation.