Zentralblatt für Chirurgie
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Pulmonary embolism is a major cause of postoperative problems, accounting for 12-20% postoperative deaths. 0.1% to 0.4% of all hospitalised patients die due to acute pulmonary embolism. Thus, pulmonary embolism should be included in the differential diagnostic considerations. Blood gas analysis, ECG, chest roentgenography, scintigraphy, pulmonary arterial catheterisation, echocardiography, digital subtraction angiography, and angiography are important diagnostic tools. ⋯ A neurosurgical operation in the preceding 10 days is still considered an absolute contraindication to thrombolysis. Patient outcome in the case of cardiopulmonary resuscitation for massive pulmonary embolism may be improved by the bolus application of 2-3,000,000 U of urokinase. In addition or alternatively, mechanical thrombus fragmentation via catheter or surgical embolectomy may be used in certain hospitals.
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Polytraumatized patients develop complex changes in blood coagulation and fibrinolysis even before their arrival at the emergency room (ER). Hemostaseological parameters (i.e. antithrombine 3, alpha-2-antiplasmine, D-dimers) obtained upon admission however, permit advance differentiation of later mortality vs. survival and of possible future secondary organ failure with varying specification. ⋯ In our study patients with multiple injuries displaying a systolic blood pressure of less than 100 mmHg either at the scene of the accident or upon arrival in the ER showed coagulation values which by other investigators were regarded as a sign of potential secondary organ failure or death.
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The multiple organ dysfunction syndrome (MODS) with a mortality of 50% to 70% represents the number 1 cause of death in surgical intensive care units. It is divided in a primary and a secondary MODS based on time of manifestation and pathophysiological events which attribute to it. ⋯ The treatment of the secondary MODS remains supportive and its prevention is essential. Further studies have to be carried out to evaluate the clinical significance of new therapeutical agents such as monoclonal antibodies or cytokine receptor antagonists.
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Cerebral lesions of variable severity lead to systemic and intracranial reactions. These create secondary brain damage due to hypoxia and ischemia. The causes as well as the sequelae of secondary brain damage necessitate long-term intensive care treatment with high technical and personal expenditure. ⋯ The decision to limit treatment should be based on the numerous national and international statistical models and discussed on an individual basis, excluding even a 5% chance of survival. Early information of the family on the probable prognosis is useful. Their participation in the process of decision can be assessed only on an individual basis.
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In contrast to earlier classifications, Tile's classification of pelvic ring disruptions considers mechanism of injury, clinical and x-ray evaluations and is therefore almost universally accepted. We propose a more comprehensive classification which gives a guide for treatment of these complex injuries. Moreover it can be used to compare results from different authors. ⋯ The location of injury is indicated by adding numbers 1-9 (1: rupture of symphysis pubis; 2: transpubic fracture; 3: acetabular fracture; 4: iliac wing fracture; 5: sacroiliac fracture-dislocation; 6: sacroiliac disruption; 7: sacral wing fracture; 8: transforaminal sacral fracture; 9: central sacral fracture). These numbers are arranged in increasing order, one hemipelvis after the other. Thus, in case of a complex pelvic injury with rotational instability on one side and vertical instability on the other each hemipelvis may be classified separately.