Spontanatmung – Schnappatmung – Beatmung?

The value of mouth-to-mouth ventilation is currently discussed because of a wide-spread fear of transmission of infectious diseases. An expert committee of the American Heart Association even considered to recommend chest compressions. In paralyzed volunteers, however, ventilation induced by chest compressions was not able to provide a sufficient gas exchange. Laboratory investigations studying ventilation during CPR showed controversial results. Animal models that prevented gasping during cardiac arrest favored ventilation during CPR, whereas gasping animals seemed to be satisfactorily ventilated with chest compressions alone. The question whether spontaneous gasping after a cardiac arrest in humans may be sufficient for oxygenation and carbon dioxide elimination remains unanswered at this point in time. Therefore, mouth-to-mouth ventilation remains the therapy of choice during basic life. If a rescuer chooses to not perform mouth-to-mouth ventilation, at least chest compressions should be administered. The value of cricoid pressure during ventilation with an unprotected airway has to be emphasized to all healthcare professionals to avoid disastrous stomach inflation. If intubation can not be performed right away, the airway may be secured with the laryngeal mask airway, combitube, larynx tube, or intubating laryngeal mask airway. Rapid intubation and ventilation with oxygen remains the state-of-the-art therapy during CPR.     

Suizid – Suizidversuch – Suizidalit?t

Background

Suicide attempts and suicidal ideation are a challenge for emergency physicians and emergency departments. These disorders are time consuming and often overwhelm staff not familiar with its diagnosis and treatment.

Medical care

The first goal of care is the establishment of a therapeutical relationship which enables a subsequent crisis intervention. Acute pharmacological treatment may be necessary, in many cases only once.

Psychiatric treatment

First, the danger of continuing self-harm must be evaluated in order to determine whether inpatient psychiatric care is required. If outpatient treatment is deemed sufficient, concrete psychiatric and psychotherapeutic support should be suggested and offered, including the help of family members.     

Akutes Nierenversagen Pathophysiologie – klinische Beurteilung – Therapie

Acute renal failure (ARF) is characterized by an acute decrease in glomerular filtration rate (GFR). ARF complicates 4% to 23% of intensive care unit admissions, and is associated with a mortality of approximately 50% among critically ill patients. In the intensive care setting the term ARF is usually applied to acute tubular necrosis (ATN), a form of intrinsic ARF caused by ischemia or nephrotoxins. Pathophysiological mechanisms involved in the decline in GFR include tubular obstruction caused by detachment of tubular epithelial cells from the basement membrane and back-leak of glomerular filtrate as a consequence of disruption of the epithelial cell layer. Vascular mechanisms involved in the pathophysiology of ATN are vasoconstriction due to an imbalance between vasoconstrictive and vasodilatory mediators and vascular obstruction caused by cell aggregation. Currently, there is no real time method to monitor renal function comparable to the real time monitoring of blood pressure or arterial oxygen saturation. Urinary output does not reflect glomerular filtration which may be critically reduced despite normal urine volumes and creatinine clearance still provides the clinically most applicable estimate of GFR. Tubular function can be assessed using the fractional excretion of sodium or the ratio of urinary and serum osmolality; both parameters can be obtained from spot samples of urine and serum and no urinary sampling period is necessary. However, both parameters are strongly affected by the administration of loop diuretics and high fluid and sodium inputs which are common in the intensive care unit. We determined the day to day variability of creatinine clearance, fractional excretion of sodium and the urinary to serum osmolality ratio in critically ill patients without renal dysfunction (i.e. creatinine clearance in the normal range) and found differences of 16% for creatinine clearance, 79% for fractional excretion of sodium and 22% for urinary to serum osmolality ratio. Treatment of ARF is mainly supportive and there is no clinically accepted therapy that attenuates the course of ATN. Treatment of the underlying disease and renal replacement therapy are the main options for the treatment of patients with ARF. In critically ill patients continuous venovenous hemo(dia)filtration is the first choice because it provides more hemodynamic and metabolic stability than intermittent therapy. Acute life-threatening hyperkalemia is an indication for intermittent hemodialysis because of the higher efficacy of dialysis in the clearance of low molecular weight substances.     

Der schwere Tauchunfall Pathophysiologie – Symptomatik – Therapie

Decompression injuries are potentially life-threatening incidents, generated by a rapid decline in ambient pressure. Although typically seen in divers, they may be observed in compressed air workers and others exposed to hyperbaric environments. Decompression illness (DCI) results from liberation of gas bubbles in the blood and tissues. DCI may be classified as decompression sickness (DCS) or arterial gas embolism (AGE), depending on where the gas bubbles lodge. DCS occurs after longer exposures to a hyperbaric environment with correspondingly larger up-take of inert gas. DCS may be classified into type 1 with cutaneous symptoms and musculoskeletal pain only or type 2 with neurologic and/or pulmonary symptoms as well. AGE usually results from a pulmonary barotrauma, and with cerebral arterial involvement, the symptoms are similar to a stroke. The most important therapy, in the field, is oxygen resuscitation with the highest possible concentration and volume delivered. The definitive treatment is rapid recompression with hyperbaric oxygen therapy. Additional therapeutic measures are discussed.     

Präklinische Testung – klinische Anwendung – Schadensanalyse

Preclinical testing – clinical application

Total hip arthroplasty has become one of the most successful procedures in orthopedics. This has been made possible through continuous improvement of the implant systems and materials accompanied by an improvement in preclinical testing and the legal framework. A further improvement in results can only be achieved if the two other decisive factors for the success of an operation are also included: intensive education and training of the surgeons combined with education and awareness of the patients.

Risk assessment

The introduction of new concepts always bears the risk of new unforeseen failure mechanisms, which cannot always be prevented by established preclinical testing. This requires the careful introduction of new concepts into clinical application, combined with a standardized failure analysis, in order to reduce the number of problem cases in the worst case situation.     

Kein Sturz – keine Misshandlung – kein seltener Befund?

A baby was brought into the accident and emergency department with X-ray pictures and with a plaster cast in place because of a pain reaction in the right arm. The pictures showed destruction of the epiphyseal region and double periosteal contours. Alterations of the same kind were found in all long bones; they were recognized as compatible with florid congenital syphilis, which was confirmed by reference to the history and the laboratory findings and was successfully treated with penicillin G in the pediatric department. Both parents were also treated. No traumatological/orthopedic treatment was given, and the plaster cast was removed. Following recognition of the signs described a complete cure was possible.     

Nierenteilresektion – pro Laparoskopie

Partial nephrectomy has become the most frequently used surgical procedure in the treatment of renal cell cancer. The current role of laparoscopy for this indication has to be defined.The technique of laparoscopic partial nephrectomy has undergone a continuous development to become mature. Once the learning curve of the individual surgeon has been overcome the results are comparable to those of open surgery. This is true for ischemia time, complication rate and oncologic outcome. In addition there is the advantage of the minimally invasive approach in laparoscopy sparing a painful flank incision. Laparoscopic partial nephrectomy is not yet a standard of care but yields excellent results in the hands of experts. There are no conclusive studies comparing standard and da Vinci?-assisted laparoscopy. No clear advantages become obvious, but the costs of the robot are substantial.     

Nierenbeckenplastik – pro laparoskopisch

With increasing experience and availability of the da Vinci? robotic surgery system there has been an extension of the indications from initially exclusively ablative interventions, such as nephrectomy and radical prostatectomy to reconstructive interventions, such as pyeloplasty, bladder augmentation and urinary diversion. Laparocopic pyeloplasty has been established for both adults and children, with results comparable to the open procedure. In comparison the conventional laparoscopic procedure is little cost-intensive and therefore widely used. The available literature has to be analysed to find advantages for the cost-intensive, robot-assisted laparoscopic pyeloplasty from which patients can profit.     

Divertikelkrankheit – operative Verfahrenswahl

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. The tenets of surgical treatment of diverticulitis are resection of the entire sigmoid and creation of a tension-free anastomosis in the upper rectum. With respect to the required extent of resection according to current data it is not necessary to remove the entire colonic segment bearing diverticula because such a strategy does not reduce the recurrence rate. In the emergency situation due to free perforation a primary anastomosis with defunctioning ileostomy should be favored because the stoma reversal rate after primary anastomosis is higher than after Hartmann’s procedure. The Hartmann procedure should be reserved for perforated diverticulitis with severe septic complications; however, the final treatment decision for primary anastomosis or Hartmann’s procedure should be dependent on the individual patient. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis as an alternative to resection surgery. In cases of diverticular bleeding a subtotal colectomy should be performed if the diverticular bleeding site cannot be localized.     

Pertrochantäre Pseudarthrosen Materialfehler – technische Fehler – naturgegeben?

Zusammenfassung. Nicht immer ist der Schmerz das führende Symptom der fehlenden Durchbauung einer nicht stattfinden Frakturheilung. Hohe Prim?rstabilit?t der Implantate erm?glicht oft eine Belastung der Extremtit?t trotz bestehender Frakturinstabilit?t. Die zus?tzlich schwierige radiologische Diagnostik einer Pseudarthrose lassen den richtigen Zeitpunkt der Intervention (Reosteosynthese) verpassen. Das Implantatversagen bzw. der Implantatbruch sind Ausdruck einer chirurgischen Fehleinsch?tzung. Somit ist die Diagnose „Pseudarthrose der pertrochant?ren Region“ eine flie?ende und wird letztendlich als eine sich nicht einstellende Frakturheilung bei noch bestehender Implantatstabilit?t definiert. Das Erkennen dieses biologischen und biomechanischen Versagens verlangt von den behandelnden Chirurgen ein subtiles Einsch?tzen der Gesamtsituation, gro?e Erfahrung in der Revisionschirurgie und Mut zur Entscheidung.      

Knieendoprothetik – Operationstechnische Aspekte

The implantation of a condylar knee has remained a challenge for surgeons and the equipment of the hospital. In contrast to total hip arthroplasty, not only is the correct insertion of the implant crucial, but also the treatment of the surrounding soft tissues. Mediolateral soft tissue balance and balance between flexion and extension gaps, as well as centering the patella, have to be done carefully. The soft tissue envelope of the knee joint is thin and prone to necrosis after multiple incisions. Damage to the extension mechanism can make a total joint useless. Tearing the patellar ligament from the tibial tuberosity must therefore be avoided by all means during operation. Precise cutting of the distal femur is only possible if excellent equipment is used by a skillful surgeon. The same is true for orientating saw cuts related to the long leg axes. These tasks can probably be taken over by navigation systems and robots in the future. Because the definite choice of implants has to be made intraoperatively, a complete modular system has to be present in the hospital. Only hospitals that can properly equip their surgeons to manage upcoming soft tissue problems and bony deficiencies should offer treatment to patients requiring condylar knee arthroplasty.     

Palliativmedizin – eine Standortbestimmung

Ohne Zusammenfassung     

Wilms-Tumor – Update 2007

Due to the close interdisciplinary work of surgeons, radiologists and oncologists, the prognosis for Wilms' tumor (the most common renal tumor in childhood) has been dramatically improved over the last few decades. The treatment of such tumors is currently carried out worldwide by two study groups, in North America the National Wilms' Tumor Study (NWTS) and in Europe the Society of Paediatric Oncology (SIOP). Here we present an overview of the current treatment results and discuss future diagnostic and therapeutic strategies.