Ultraschallgesteuerte perivaskuläre axilläre Plexusanästhesie

BACKGROUND: The perivascular axillary plexus block is an easily applicable procedure with a low risk of complications but with a high failure rate. To improve this, the standard procedure was combined with transpectoral sonography to benefit from the advantages of ultrasound, while using a nearly unchanged puncture technique. METHOD: The technique developed by the authors is described in this article and the success rate and the time factor were determined in a sample of 86 patients. The success rates were compared to previous rates without ultrasound and to those in the literature. RESULTS AND CONCLUSIONS: The rate of complete blocks without the use of transpectoral sonography in our clinic and in the literature was approximately 72%, whereas using transpectoral ultrasound it was 96.5%. None of the 86 patients with transpectoral sonography required general anaesthesia. The onset time using transpectoral sonography was approximately 6 min. The perivascular axillary plexus block, combined with transpectoral sonography, is an effective and efficient procedure.     

Patientengefährdung durch Gerätediversität?

Background

The Federal Institute for Drugs and Medical Devices (BfArM) was notified of an event in which it was not possible to sufficiently ventilate a patient suffering a severe asthma attack. It turned out that the ventilation pressures used by the device for pressure-controlled ventilation were below the values set by the user, which the user was not aware of. The ventilation pressures chosen by the user exceeded the preset alarm limits of the ventilator. This pressure and alarm management significantly differed from that of other ventilators used in the hospital. This and similar incident reports suggest that safely operating medical devices for anesthesia and intensive care may be impaired when different models of a device are used within a hospital. If different models are used, more device information needs to be stored in memory. Existing knowledge on human memory suggests that the more individual memory items (e.?g. different operating rules) are stored, the greater the risk of memory interference and hence of impaired retrieval, particularly if the different items are associated with overlapping retrieval cues. This is the case when different devices are used for a single functional purpose under identical or similar circumstances.

Objective

Based on individual incident reports and theoretical knowledge on an association between device diversity and use problems, this study aimed to determine the organizational conditions regarding device diversity that prevail in German hospitals. Additionally, the anesthetists’ perspectives and experiences in defined clinical settings were investigated.

Methods

For selected groups of medical devices, the biomedical engineers of German hospitals were surveyed about the different makes used in their hospital. Additionally, questionnaires were sent to a department of anesthesiology of a large University Hospital to investigate the personal experiences of working with different makes and models of a device.

Results

Using devices by different manufacturers was particularly frequent for ventilators, but there were also a considerable number of hospitals with syringe pumps and patient monitoring systems from different manufacturers. Almost all participants stated that they work or have worked with different models of a device. The majority of respondents had encountered problems or errors, which they ascribed to the requirement to learn a different method of operation for each device; however, they also listed various benefits, for instance the possibility to optimally address the requirements of specific situations or patient groups. Both biomedical engineers and anesthetists suggested a homogeneous device pool within the hospital and regular and repeated training sessions for each device model used.

Discussion

Using different device models for anesthesia and intensive care seems to be common in many German hospitals, particularly for ventilators. An association between device diversity and problems operating a device is plausible, given the functioning of human memory. This topic should be investigated by future studies in order to identify factors that may contribute to such problems and possible solutions for clinical settings. Likewise, the potential benefits of having different device models at one’s disposal should be evaluated. To pinpoint the measures that will be most effective given the specific settings of the individual hospital, all underlying clinical and economic considerations must be carefully balanced against the associated potential risks.

     

Neurogene Wirbelsäulendeformitäten

Sitting is a dynamic process regulated by motor reactions due to endogenic and exogenic influences. Patients with neuromuscular disorders may not continuously adapt their sitting posture but seating devices may improve their quality of life. Prerequisites for the indication of high quality and cost effective seating devices are guidelines for planning and fitting which consider both pathomorphologic mechanisms and the patient's personality. In order to avoid functional problems and pain caused by an insufficient seating device it is necessary to pay attention to the exact indication, time, and combination of technical options. Planning within a seating clinic needs teamwork. First the goal of treatment is defined; it depends on the functional deficit, on the daily living activities of the patient, and on the social environmental factors. Second fitting of the devices follows defined treatment guidelines. By examination of the sensoric and statomotoric system it is possible to classify the patient's sitting or seating ability for simplifying indication: three groups of active sitters who are able to change position of trunk and pelvis actively are differentiated from three groups of passive sitters who have to be seated.     

Hypovolämisch-hämorrhagischer Schock

The term “shock” refers to a life-threatening circulatory failure caused by an imbalance between the supply and demand of cellular oxygen. Hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in preload. The body compensates the loss of volume by increasing the stroke volume, heart frequency, oxygen extraction rate, and later by an increased concentration of 2,3-diphosphoglycerate with a rightward shift of the oxygen dissociation curve. Hypovolemic hemorrhagic shock impairs the macrocirculation and microcirculation and therefore affects many organ systems (e.g. kidneys, endocrine system and endothelium). For further identification of a state of shock caused by bleeding, vital functions, coagulation tests and hematopoietic procedures are implemented. Every hospital should be in possession of a specific protocol for massive transfusions. The differentiated systemic treatment of bleeding consists of maintenance of an adequate homeostasis and the administration of blood products and coagulation factors.     

Präklinische Kindernotfälle

Background

Out-of-hospital (OOH) pediatric emergencies have a relatively low prevalence. In Germany the vast majority of cases are attended by non-specialized emergency physicians (EPs) for whom these are not routine procedures. This may lead to insecurity and fear. However, it is unknown how EPs perceive and assess pediatric emergencies and how they could be better prepared for them.

Methods

All active EPs (n=50) of the Department of Anaesthesiology, Emergency and Intensive Care Medicine at the University Medical Centre of Göttingen were presented with a structured questionnaire in order to evaluate their perception and assessment of OOH pediatric emergencies.

Results

The 43 participating EPs made highly detailed statements on the expected characteristics of OOH pediatric emergencies. Their confidence level grew with the children’s age (p<0.03) and with their own experience (p<0.01). The EPs felt particular deficits in the fields of cardiopulmonary resuscitation (n=18) and trauma management (n=8). The preferred educational strategies included simulator-based training (n=24) as well as more exposure to pediatric intensive care and pediatric anesthesia (n=12).

Conclusions

Despite their own limited experience EPs can realistically assess the incidence and severity of pediatric emergencies. They felt the greatest deficits were in the care of infrequent but life-threatening emergencies. Three educational groups can be differentiated: knowledge and skills to be gained with children in hospital, clinical experience from adult care also applicable in children and rare diagnoses and interventions to be trained with manikins or simulators.     

Qualitätssicherung Hämotherapie in der Anästhesie

BACKGROUND: The measures for quality assurance in haemotherapy developed at the Charite Campus Mitte according to the transfusion law of 1998 are introduced and discussed. METHODS: In a 3-year study period the submission of transfusion documentation and the expiration of blood products were compared to the year 2001. The potentials for improvement for 2001-2003 were compared based on evaluation of the self-inspection documentation of the transfusion clinics. RESULTS: The submission rate for the transfusion documentation increased from 90% in 2001 to 98.3% in 2002 and 2003. The expiration of blood products decreased from 5.1% in 2001 to 1.7% in 2003 resulting in a cost reduction from 140,000 Euro to 50,000 Euro. Continuous need for improvement was found for the prescribed annual further education of staff on quality management. CONCLUSIONS: The self-inspection procedure in transfusion clinics still revealed potential for improvement, although documentation of transfusions were improved and the expiration of blood products and the resulting costs were substantially reduced.     

Methämoglobinämie durch Prilocain nach Plexusanästhesien

ZusammenfassungZiel der Studie Die Studie soll die In-vivo- und In-vitro-Kinetik der o-Toluidin-vermittelten Methämoglobin- (MetHb-)Bildung sowie deren Beeinflussbarkeit durch Ascorbinsäure klären. o-Toluidin ist ein Metabolit des Prilocain; Vitamin C wird als Alternative zu Methylenblau zur Therapie der Methämoglobinämie empfohlen.Methodik Die In-vitro-Messungen zur MetHb-Bildung wurden an Vollblutansätzen von 8 Probanden mit verschiedenen o-Toluidin-Konzentrationen (0,5, 5, 50 µg/ml) ohne und mit Vitamin-C-Zusatz (0,5 und 5 mg/ml) durchgeführt. Die MetHb-Bestimmungen erfolgten vor sowie 30, 60 und 360 min nach Zugabe von o-Toluidin und Vitamin C. In der prospektiven, randomisierten klinischen Studie wurden insgesamt 72 chirurgische und orthopädische Patienten der ASA-Klassen I–III eingeschlossen. Je 24 Patienten erhielten zur Operation eine axilläre oder vertikal-infraklavikuläre Plexusanästhesie oder einen kombinierten Ischiadikus- und Femoralisblock. Je 12 Patienten pro Gruppe erhielten vor Anlage der Regionalanästhesie 2.000 mg Vitamin C i.v.. Bei Eingriffen an der oberen Extremität wurden 40 ml 1%iges Prilocain und 10 ml 0,5%iges Bupivacain und an der unteren Extremität 60 ml 1%iges Prilocain mit 0,25 mg Adrenalin appliziert. Die MetHb-Konzentrationen im Blut der Patienten wurden vor sowie 30, 60, 120, 180 und 360 min nach Anlage der Anästhesie gemessen. Ein p<0,05 wurde als statistisch signifikant angesehen.Ergebnisse In vitro zeigt sich nach 360 min ein signifikanter dosisabhängiger Anstieg der o-Toluidin-vermittelten MetHb-Bildung. Mit 0,5 mg/ml Vitamin C nimmt bei 0,5 µg/ml und 5 µg/ml o-Toluidin die MetHb-Bildung weiter zu, nicht jedoch bei 50 µg/ml o-Toluidin. Die Gabe von 5 mg/ml Vitamin C führt dagegen bei 50 µg/ml o-Toluidin zu einer Verringerung der MetHb-Konzentration. Bei den niedrigeren o-Toluidin-Konzentrationen hat Ascorbinsäure keinen Effekt auf die MetHb-Konzentration. In vivo kommt es nach Plexusanästhesie mit Prilocain zu einem Anstieg der im Blut gemessenen MetHb-Konzentrationen mit einem Maximum nach 120–180 min. Der gemessene Maximalwert der MetHb-Konzentration lag bei 11,3%. Nach 360 min lässt sich bereits wieder ein Abfall der MetHb-Konzentrationen nachweisen. Die i.v.-Gabe von 2.000 mg Vitamin C vor Anlage der Plexusanästhesie beeinflusst nicht die resultierenden MetHb-Konzentrationen.Schlussfolgerung In vitro kann mit hohen unphysiologischen Vitamin C-Konzentrationen der o-Toluidin-vermittelte Anstieg der MetHb-Konzentration nach 360 min reduziert werden. Mit der i.v.-Gabe von 2.000 mg Vitamin C vor Anlage einer Plexusanästhesie mit Prilocain lässt sich der Anstieg der MetHb-Konzentration jedoch nicht beeinflussen.     

Neurogene Wirbelsäulendeformitäten

Neurogenic spinal deformities develop primarily due to insufficient dynamic stabilization against gravity. Unilateral muscle overactivity is another but rare cause. The aim of treatment is to provide stability as well as to prevent deformity. In mild cases, the treatment of choice is a spinal brace because stabilization can be combined with residual mobility and adequate correction of shape. Seating shells are more readily accepted but less appropriate for this purpose. In severe cases, surgery is a good option despite the considerable effort involved and high rate of complications.     

Testikuläre Ischämie

Background

Ischemia and reperfusion (I/R) lead to cellular damage. A disturbance of testicular perfusion occurs during the therapy of cryptorchidism and in cases of testicular torsion. This results in the activation of mediator cells with an increasing synthesis of mediators of infection like TNF-α and the expression of cell adhesion molecules like ICAM (intercellular adhesion molecule) and VCAM (vascular cell adhesion molecule) at the cellular surface.

Methods

The expression of the cytokines IL-10 and TNF-α and the adhesion molecules ICAM and VCAM after defined testicular I/R injury in nine male transsexuals was evaluated with rt-PCR. Furthermore we examined lactate and the diameter of the testicular tubulus under ischemic conditions.

Results

During ischemia ICAM, IL-10, and VCAM do not show significant changes on the side of testicular ischemia and the contralateral side; the same was seen for the tubulus diameter. TNF-α and the testicular lactate values showed a significant change of the expression pattern.

Discussion

The statistical changes of TNF-α and testicular lactate are the expression of leukocyte migration, infectious reaction, and immune response. To what extent the TNF-α expression represents a severe immunological reaction remains undefined. This human study shows primary results for the immunological understanding of and cellular response to testicular ischemia.     

Pädiatrische Notfälle in der präklinischen Notfallmedizin

BACKGROUND: The aim of this study was to demonstrate differences in structure and severity of pediatric emergencies treated by aeromedical (air rescue) or ground ambulances services. Conclusions for the training of emergency physicians are discussed.PATIENTS AND METHODS: In a 3-year study period, a total of 9,274 pediatric emergencies covered by the ADAC air rescue service are compared to 4,344 pediatric patients of ground ambulance services in Saarland.RESULTS: In aeromedical services pediatric emergencies are more frequent (12.9% vs. 6.4%), trauma predominates (59.9% vs. 35.6%) and severe injuries or diseases occur more frequently (30.5% vs. 15.0%). In both groups pediatric emergency cases are concentrated into very few diagnostic groups: more than one third of the cases involving pre-school children is due to convulsions. Respiratory diseases and intoxication are the next most frequent causes and are more common in ground ambulance patients. Head trauma is the most common diagnosis in cases of pediatric trauma, followed by musculoskeletal and thoracoabdominal trauma. All types of severe trauma are more frequent in pediatric patients of the aeromedical services.CONCLUSIONS: Training of emergency physicians should include pediatric life support and specific information about frequent pediatric emergency situations. For emergency physicians in aeromedical services, an intensive training in pediatric trauma life support is also necessary.     

Die Hämangiome und Osteohämangiome der Schädelknochen

Zusammenfassung Darstellung der Klinik und Pathologie des Hämangioms der Schädelknochen an Hand von sieben Fällen.Diese gutartigen Geschwülste werden meist im mittleren Lebensalter vorwiegend an den Stirn-und Scheitelbeinen und nur sehr selten an der Schädelbasis beobachtet. Sie sind bei Frauen doppelt so häufig wie bei Männern. Die klinischen Erscheinungen sind uncharakteristisch. Der Operateur kann das Knochenhämangiom an der dunkelblau violetten Färbung erkennen. In einem Teil der Fälle ist das Röntgenbild durch einen umschriebenen Aufhellungsherd mit feinnetzig gezeichnetem Grund, etwas schattendichterem Zentrum, gezähntem Rand und lichtstrahlenartigen Spiculae gekennzeichnet. Das Röntgenbild ist aber nicht pathognomonisch, es können ihm in einzelnen Fällen auch Prozesse anderer Genese zugrunde liegen. Manche Schädelhämangiome stellen sich überhaupt nur als völlig uncharakteristische Aufhellungsherde dar.Histologisch handelt es sich in der Mehrzahl der Fälle um einfache, im Knochen gelegene, kavernöse Hämangiome. Seltener sind kavernöse Osteohämangiome, bei denen sich im Grundgewebe der Geschwulst nebem den Bluträumen auch neue Knochenbälkchen entwickeln. Schließlich gibt es am Schädel noch Osteohämangiome mit Ausbildung kavernöser und capillarer Gefäße.Mit 10 Textabbildungen     

Wirbelsäulenverletzungen und Unfallfolgezustände

The aim of computer-assisted navigation procedures is to increase the anatomical orientation intraoperatively, to improve the accuracy, to minimize the invasiveness and to reduce the emission of radiation. In the field of orthopedic surgery navigation has been used for over 15 years and these techniques are particularly widely used in spinal surgery. There are three major applications of navigation: CT-based (computed tomography) navigation which needs a preoperative CT scan, 2D navigation which is based on standard X-ray images of a C-arm during surgery and 3D navigation which requires an intraoperatively performed C-arm based 3D scan. Higher accuracy has been proven for instrumentation of the lumbar and cervical spine and reduced emission of radiation could be demonstrated. Higher accuracy for pedicle screw insertions of the thoracic spine is still not proven in prospective studies with sufficient numbers of pedicle screws. Navigation systems provide additional information for better anatomical orientation in spinal surgery and can reduce intraoperative fluoroscopy time. Intraoperative 3D scan technology with automatic registration is the perfect tool in spinal surgery today. Knowledge of the classical techniques remains crucial for the safety of patients.     

Verlängerungsosteomien bei Beinlängendifferenzen

Callus distraction is the standard procedure for the operative treatment of leg length discrepancy. The deformity is analysed prior to surgery. Clinical assessment and imaging allow precise quantification. The procedure is performed by ring or unilateral frame and or i.m. nail in a continuous mode. The bone cut is performed percutaneously. Associated axial or rotational deformities are corrected simultaneously--acutely or in a continuous mode. Callus distraction is preferably applied during childhood. For good outcome control of the patient is important during the inpatient and outpatient treatment. Physiotherapy and orthotic treatment are mandatory, the same as the management of complications.     

Die stabilitätsgefährdenden Metastasen

Zusammenfassung. Die Behandlung von Tumorpatienten mit oss?rer Metastasierung ist heutzutage eine vorrangig interdisziplin?re Aufgabe mit der Erstellung eines multimodalen Therapiekonzeptes, in dem die operative Therapie bezüglich des Zeitpunktes und des Umfanges des Eingriffs optimal einzuordnen ist. Ein multimodales Therapiekonzept beinhaltet neben der operativen Therapie die systemische Tumorbehandlung (Chemo-, Hormon- und Immuntherapie), die Strahlentherapie und andere medikament?se Therapieverfahren (z. B. Osteoklastenhemmer). Für die operative Therapie stehen neben den klassischen Verfahren wie die Verbundosteosynthese oder intramedull?rer Stabilisierung neue winkelstabile Implantate sowie moderne modulare Tumorendoprothesensysteme, die nach weitestgehender Tumorresektion eine Defektüberbrückung in einem Gro?teil der Skelettlokalisationen erm?glichen, zur Verfügung. Ziel der operativen Behandlung mu? sein, dem Patienten die Stabilit?t und Funktion der betroffenen Regionen und damit seine Mobilit?t wiederzugeben bei gleichzeitiger Schmerzreduktion, damit der noch verbleibende Lebensabschnitt mit einer akzeptabelen Lebensqualit?t verbunden bleibt.      

Anwendungsbeschränkung für Hydroxyäthylstärke

Background

Within the framework of a risk assessment procedure the Committee for Risk Assessment of Pharmacovigilance (PRAC) of the European Medicines Agency (EMA) came to the conclusion that the benefits of hydroxylethyl starch infusion solutions (HES) no longer outweighed the risks and on 14 June 2013 recommended that approval should be suspended. Until the procedure has finally been concluded, which could last several months, the Federal Institute for Drugs and Medical Products (BfArM) has recommended that HES should not be used.

Aim

The aim of this article is to present the data situation in the most objective and compact way and to ultimately give the reader the foundations in order to be able to form a personal opinion. In addition an attempt will be made to describe a concept how infusion therapy can be carried out without using hydroxyethyl starch (HES).

Material and methods

The background to this decision is given based on a review of the literature and the relevance for intensive care, emergency and perioperative medicine is assessed. Furthermore, a concept of infusion therapy without hydroxyethyl starch is formulated also based on the results of current studies.

Results

For infusion regimens without HES it should be noted that gelatin represents a considerable risk for anaphylactic reactions, that transfer of the new variants of Creutzfeldt-Jacob disease (bovine spongiform encephalopathy BSE) cannot fundamentally be excluded and that some evidence has been found that gelatin can cause kidney injury, probably in a similar way to HES. With respect to the cost-benefit analysis of infusion solutions, blood loss in adults of approximately 1-1.5 l can be substituted by balanced crystalloids (basic therapy 4–5 times compared to the amount of blood lost). For larger blood losses small amounts of hyperoncotic albumin solution (20 %) or alternatively 5 % albumin solution can be used. The 20 % albumin solution seems to have some advantages because it has a higher volume effect (approximately 200 %) and can be more favourable for the fluid balance than 5 % albumin solution. Blood losses greater than 2-3 l normally also require administration of blood products (e.g. fresh frozen plasma FFP and erythrocyte concentrates EC).

Conclusions

The third generation HES solutions cannot be completely replaced by other colloids and in future crystalloids will more strongly again broadly form the basis for infusion therapy. In this aspect balanced crystalloids have priority with respect to the acid-base equilibrium. The history of HES has impressively shown that infusion therapy must be adjusted on a scientifically founded basis, whether in intensive care medicine, perioperative or emergency medicine. Large prospective studies with clinically relevant endpoints are urgently needed.     

Einfluss der akuten normovolämischen Hämodilution auf die primäre Hämostase

Background

Acute normovolemic hemodilution (ANH) is performed with the intention to reduce the requirement for allogeneic blood transfusions. After preoperative withdrawal of whole blood, corresponding amounts of crystalloids and/or colloids are infused to maintain normovolemia. The main benefit of ANH is the availability of whole blood containing red blood cells, clotting factors and platelets for reinfusion after removal during the dilution process. Until retransfusion whole blood components are stored at the patient’s bedside in the operating theatre.

Aim

It was the aim of the present investigation to analyze potential changes in ex vivo induced platelet aggregation in stored blood components.

Material and methods

After obtaining approval 15 patients undergoing complex cardiac surgery were enrolled into this prospective observational study. Acute normovolemic hemodilution (ANH) was routinely performed in this collective based on institutional standards. Besides analyses of pH and plasma concentrations of ionized calcium and hemoglobin, hematological analyses included aggregometric measurements using multiple electrode aggregometry (MEA, Multiplate®, Roche, Grenzach, Germany). Ex vivo platelet aggregation was induced using arachidonic acid (ASPI test), as well as thrombin receptor activating peptide (TRAP test) and adenosine diphosphate (ADP test). Laboratory analyses were performed before beginning ANH (baseline), as well as immediately (T₁), 30 min (T₂), 60 min (T₃), 90 min (T₄), 120 min (T₅), 150 min (T₆) and 180 min (T₇) after beginning of storage. The areas under the aggregation curves (AUC) in the MEA were defined as primary (ASPI test) and secondary endpoints (ADP test, TRAP test).

Results

As compared to baseline, arachidonic acid induced platelet aggregation was significantly reduced at T₁ [77 U (68/94 U) vs. 53 U (25/86 U), p?=?0.003] and each consecutive measuring point. As compared to T₁ (begin of storage), arachidonic acid induced platelet aggregation was significantly reduced at T₄ [26 U (14/54 U); p?=?0.002], T₅ [30 U (21/36 U); p?=?0.007], T₆ [25 U (17/40 U); p?=?0.004] and T₇ [28 U (17/39 U); p?<?0.001]. The extent of ex vivo induced platelet aggregation in the TRAP test and ADP test remained unchanged during the study period. The pH as well as the concentrations of ionized calcium and hemoglobin remained unchanged in the blood component during storage.

Conclusion

The results of the present study indicate that disturbances of platelet aggregation may occur during storage of whole blood components prepared for the purpose of ANH. Further investigations are needed to analyze whether the observed phenomena are of hemostatic relevance.     

Myotoxizität von Lokalanästhetika

Intramuscular injections of local anaesthetic agents regularly result in reversible muscle damage, with a dose-dependent extent of the lesions. All local anaesthetic agents that have been examined are myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury. The histological pattern and the time course of skeletal muscle injury appear relatively uniform: hypercontracted myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic reticulum myocyte edema and necrosis. Intriguingly, in most cases myoblasts, basal laminae and connective tissue elements remain intact which subsequently ensures complete muscular regeneration. Subcellular pathomechanisms of local anaesthetic myotoxicity are still not understood in detail. Increased intracellular Ca(2+) levels are suggested to be the most important element in myocyte injury, since denervation, inhibition of sarcolemmal Na(+) channels and direct toxic effects on myofibrils have been excluded as sites of action. Although experimental myotoxic effects are impressively intense and reproducible, only few case reports of myotoxic complications in patients after local anaesthetic administration have been published. In particular, the occurrence of clinically relevant myopathy and myonecrosis has been described after continuous peripheral blockades, infiltration of wound margins, trigger point injections, peribulbar and retrobulbar blocks.     

Primärprävention des Blasenkarzinoms

Bladder cancer (Bc) with an incidence of 8.6% ranks fourth in males and with an incidence of 3.5% ranks eighth in females in Germany. The study of Cole demonstrating that coffee drinking poses a risk for developing Bc raised interest in primary prevention. In the meantime, however, 42 case-control studies could disprove this finding. Cigarette smoking raises the Bc risk threefold. Responsible are among others arylamines which are activated in the liver, but also detoxified. A genetically caused lack of transferases is responsible for every third Bc. Another risk factor is contributed by permanent hair dyes. Similarly to smoking, an arylamine is taken up by the body and has to be detoxified by transferases in the liver and skin. Furthermore, a chronic urinary tract infection may be related to Bc. Thus, the best prevention is the reduction of risk factors.A high fluid intake--irrespective of its kind--reduces the Bc risk by approximately 50%. Particularly smokers should realize that they can lower their risk of developing Bc by almost 70% with a high fluid intake. A connection between alcohol consumption and Bc development has never been shown. Vitamins A, B, and C were extensively investigated in epidemiological studies. Usefulness for primary prevention of Bc was not convincingly demonstrated. Interestingly, folic acid-containing food may reduce the Bc risk for smokers. Fruits and vegetables possess only a weak preventive efficacy. However, copious fruit consumption may reduce the risk for smokers by almost 50%.The trace element selenium does not possess a proven protection; however, it has been shown that persons with a high selenium plasma level have a lower incidence of Bc. Among probiotics yogurt containing Lactobacillus casei is particularly useful in smokers according to one study. Finally, the preventive action of NSAIDs is controversial. Surprisingly, users of analgetics have a low incidence of Bc.     

Zuverlässigkeit notärztlicher Verdachtsdiagnosen

Background

Trauma is the leading cause of death in the patient group under 40 years of age. Within the prehospital management of seriously injured trauma victims the accuracy of the field triage by emergency physicians is of utmost importance.

Objective

The aim of this study was to determine the accuracy of prehospital emergency physician field triage in road traffic accident victims.

Material and methods

The study involved a retrospective analysis and comparison of prehospital and inhospital trauma records of road traffic accident victims treated by a Helicopter Emergency Medical Service (HEMS) team and transferred to a level I trauma centre. A comparison of prehospital and inhospital diagnostic findings was carried out according to an anatomical score (AIS).

Results

Included in the analysis were 479 patients with a mean age of 37.0?±?18.2 years, males 65.8?%, mean injury severity score (ISS) 15.5?±?13.5, ISS >?16 in 41,1?% and mortality 7.3?%. The leading causes of injury were motor vehicle accidents (56.2?%), followed by motorcycle (24.0?%) and bicycle accidents (11.6?%) as well as truck accidents (4.0?%) and pedestrian accidents (4.2?%). The most common body regions injured (AIS ≥?3) were the chest (37?%), head (25.1?%) and lower extremities (16.7?%). A correct prehospital field triage by emergency physicians was found for injuries with an AIS ≥?3 of the head 77?%, chest 69?%, abdomen 51?%, pelvis 49?%, extremities 70?%, neck/cervical spine 67?% and thoracic/lumbar spine 70?%. Overlooked injuries in the prehospital setting (AIS ≥?3) comprised predominantly injuries of the trunk (chest 12.6?%, abdomen 16.9?% and pelvis 15?%). Overlooked injuries were found significantly less for the head in patients with a Glasgow Coma Score ≤?8 on arrival at the scene (5.4?% versus 19?%, p?=?0.015), for the chest in patients with a S_pO₂?≤?96?% on arrival at the scene (18.1?% versus 35.5?%, p?=?0.004) and for the abdomen in patients with a systolic blood pressure <?90 mmHg on arrival at the scene (28.6?% versus 52.5?%, p?=?0.025).

Conclusion

Accurate field triage in seriously injured road accident victims, even by trained physicians, is difficult. This pertains especially to injuries to the abdomen and the pelvis. For the field triage a combination of anatomical and physiological criteria as well as the mechanism of injury should be used to increase accuracy.