Articles: treatment.
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Dtsch. Med. Wochenschr. · Jan 2001
[Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma]
An 18-year-old previously healthy, cigarette smoking man with no other risk factors for ischaemic heart disease, was admitted to hospital after being kicked in the chest by a horse. On arrival he complained about pain in the lower mediastinum. INVESTIGATIONS: The ECG showed sinus rhythm, right bundle branch block and convex bowed ST elevation in leads V1-V3. Sixty minutes after the incident the cardiac enzymes (creatinekinase-MB fraction, troponin I) were significantly raised. Despite an only slightly reduced left ventricular function documented by transthoracic echocardiography, SPECT-thallium scan showed large scintigraphic defects. Coronary heart disease was excluded by coronary angiography. Four small coronary-ventricular fistulas were identified. Laevocardiography showed a hypokinesia in the antero-septal region. DIAGNOSIS, TREATMENT AND COURSE: We assumed traumatic myocardial infarction of the anterior wall and rupture of multiple small coronary vessels, leading to coronary-ventricular fistulas. No interventional or surgical therapy was performed. Later on the left ventricular function became normal. Echocardiography merely outlined an akinetic scar in the middle of the septum. At exercise ECG test sixteen months later, the patient remained asymptomatic and was able to exercise without any signs of ischaemia up to a work load of 175 W. Furthermore, the fistulas could be seen by echocardiography. ⋯ Cardiac involvement should be considered in all cases of blunt chest trauma. In addition to a traumatic myocardial infarction fistulas may also, though rarely, occur. Myocardial scintigraphy after cardiac contusion is not suitable for diagnosing myocardial ischaemia or vitability.
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Semin Respir Crit Care Med · Jan 2001
Multidisciplinary management of sedation and analgesia in critical care.
Management of sedation and analgesia in critical care medicine is a multidisciplinary process that involves physicians, nurses, pharmacists, and other healthcare providers. Optimal management of these common issues includes recognition of the importance of predisposing and causative conditions that contribute to the sensations of pain and discomfort, anxiety, and delirium. ⋯ Optimal use of sedative and analgesic medications involves matching unique properties of specific medications with individual patient characteristics. Guidelines that minimize unnecessary variability in practice, prevent excessive medication, and emphasize management based on individual patient characteristics improve the effective utilization of these medications.
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The practice guidelines for interventional techniques in the management of chronic pain are systematically developed statements to assist physician and patient decisions about appropriate health care related to chronic pain. These guidelines are professionally derived recommendations for practices in the diagnosis and treatment of chronic or persistent pain. They were developed utilizing a combination of evidence and consensus based techniques, to increase patient access to treatment, improve outcomes and appropriateness of care, and optimize cost-effectiveness. ⋯ These guidelines do not constitute inflexible treatment recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, personal needs, and preferences, and the physician's experience. Based on an individual patient's needs, treatment different from that outlined here could be warranted.
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During the last 25 years, there have been substantial advances in our understanding of the physiology and pathophysiology of pain. The development of animal models that more closely mimic clinical pain in humans has helped elucidate the putative mechanisms by which chronic pain develops and is maintained. However, our increased understanding of the neurobiology of pain has not translated into breakthrough treatments for pain management. ⋯ This retrospective validation of "novel" analgesics in animal models of pain raises a question of the predictive validity of these models. This article reviews the use of several adjuvant and standard analgesics currently used to treat difficult-to-manage pain. What can these drugs teach us about the development of novel pain medicines? Within this context, the use of animal models of pain to predict analgesic efficacy in clinical pain conditions is considered.
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To identify where most efforts should be made to decrease ischemia time and necrosis in acute compartment syndrome (ACS) and to determine the causes for late interventions. ⋯ ACS is a limb-threatening condition for which early intervention is critical. Substantial delays occur after the time of patient presentation. For traumatic and non-traumatic ACS, increased physician awareness and faster operating room access may reduce treatment delays and prevent disability.