Khirurgii͡a
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Thoracic and associated injuries pose problems demanding enormous interdisciplinary efforts regardless of the improved organizational, diagnostic and treatment potentialities. As shown by the experience of the Emergency Surgery Section at the Pirogov Institute, rendering medical services to patients presenting chest and associated injuries require coordinated integration of specialists from various profiles along with specification of the priorities and hierarchy of the emergency measures undertaken. ⋯ Chest injuries are divided in close and open injuries--2843 and 444, respectively; the latter include 29 gunshot and 415 penetrating-incise wounds. The abdominal trauma group includes 679 cases, distributed as follows: spleen rupture--341, disruption of liver and mesenterium--151, and lesion to a hollow abdominal organ--187.
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In closed thoracoabdominal trauma the diagnosis rupture of the diaphragm is usually made in 5 per cent of the casualties. Over a 12-year period (1985 through 1996), in the Pirogov Institute are admitted 3018 cases presenting polytrauma. ⋯ Open injuries associated with lesion to the diaphragm are due to gunshot wounds in two cases, and inflicted by knife and other pointed objects in nineteen. In closed trauma there is 2:1 male-to-female ratio, and in open injuries--5:1.
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A contingent of patients presenting closed chest injuries, sustained over a 12-year period (1985-1996), are analyzed. Of the total of 6938 traumas, chest injuries amount to 3286 (47.06 per cent) of which 2842 (40.7 per cent)-closed. Of the latter 2248 (79.09 per cent) are located in the left thoracic half, 420 (14.77 per cent)-in the right thoracic half, and in 174 (6.12 per cent) it is a matter of bilateral involvement. ⋯ Of the latter 14 are located in the manubrium sterni region, twelve--in the middle portion, and two in the distal part of the sternum. Over the last 5 years (1991 through 1995), of 63 casualties with flail chest 16 are with indications for stabilization osteosynthesis, and accordingly subjected to operation. A Schimelmann plate is used in 13 cases, artificial rib type "Ampar"--in three, and sternal stabilization--in one.
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According to literature data Atracurium besylate is a nondepolarizing muscle relaxant akin to the "ideal", insofar as it is governed by the "dose-relaxation time" principle. To secure normal clinical effect, doses in the range 0.4-0.5 mg/kg body mass are recommended, with the maximal manifestation of neuromuscular block occurring within 4.6-7.7 min, and lasting for 35.1 to 39.2 minutes. Maintenance dose: 0.05-0.1 mg/kg body mass. ⋯ A significant muscle relaxation with virtually twice as long duration (35-101 min) is noted, attributable to the presence of metabolic acidosis ("0.605), interfering with the normal course of the Hoffmann reaction for Atracurium disintegration. In the genesis of the phenomena observed any central mechanisms, e.g. hyperventilation, overdosage of the anesthetic, hypothermia and the like, are ruled out. In patients with acidosis it is advised to handle the muscle relaxant with greater caution.