手术室外的紧急气道处理

手术室外的紧急气道处理尚无规范。需要在各医院制定合理的紧急气道处理程序及培训相关人员。本文综述了Manual of Emergency Airway Management（Ron M．Walls）一书．明确了紧急气道处理的指证,阐述了快速序贯诱导插管法（RsI）的重要地位和具体应用方法．并针对临床具体病理状态提出相应的气道处理策略．如颅内高压．循环衰竭．胸部创伤、哮喘和颈椎损伤等情况。困难气道和失败气道应合理应对．可视喉镜技术将显示其重要作用。     

Emergency intravenous cholangiography in patients with acute abdominal pain

A prospective study of diagnostic emergency intravenous cholangiography was conducted in fifty-five selected patients with acute abdominal pain. When hepatic function was adequate, opacification of all or part of the biliary system occurred in 96 per cent of patients. The presence of pancreatitis rarely precluded a successful study. At least 85 per cent of the cholangiograms were considered diagnostically helpful, whereas 38 per cent significantly altered the admitting diagnosis.     

年轻人腹主动脉瘤九例临床分析

目的探讨年轻人腹主动脉瘤(AAA)的临床特征、治疗和预后。方法回顾性分析244例AAA中9例(37%)年龄小于35岁的年轻患者的诊治经过。结果本组男7例,女2例,年龄21～35岁,临床表现腹部或腰背部痛、腹部搏动性肿物。瘤体直径(65±09)cm。4例行择期手术均成功,3例急诊手术1例成功,2例入院后未能手术治疗者均死亡。结论年轻人的AAA有病程短、瘤体较大且较多累及腹主动脉近端,症状重的特点,应尽早手术治疗。     

The Benefit of Multislice CT in the Emergency Room Management of Polytraumatized Patients

The early treatment of polytraumatized patients needs an effective and standardized approach. Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice-CT (MSCT) is a quick and reliable method for the initial diagnostic evaluation. Computed tomography provides more detailed and more consistent information than conventional radiography. It has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen and pelvis during one single examination. The CT-suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiological investigations.

Since polytrauma management is based on a multidisciplinary approach characterized by a coordinated interaction between trauma surgeons, anaesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.     

The Benefit of Multislice Computed Tomography in the Emergency Room Management of Polytraumatized Patients

Abstract Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice computed tomography (MSCT) is a quick and reliable method for the initial diagnostic evaluation. CT provides more detailed and more consistent information than conventional radiography and it has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen, and pelvis during one single examination. The CT suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiologic investigations.Since polytrauma management is based on a multidisciplinary approach that is characterized by a coordinated interaction between trauma surgeons, anesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.     

Right paraduodenal hernia: a source of chronic abdominal pain in the adult.

Right paraduodenal hernias are a relatively rare congenital malformation with a total of 50 clinical cases having been reported. This anomaly can be seen as total encapsulation of the small bowel or a single loop within a hernia sac. Symptoms are often chronic vague abdominal pain and intermittent obstructive episodes. Barium studies in patients with moderate and large defects, and angiography in small hernias may provide the diagnosis. The method of repair is dependent on the size of the hernia encountered. The management of two patients with this problem is described.     

Acute abdominal pain in the emergency department - a clinical algorithm for adult patients

Acute abdominal pain represents the cardinal symptom behind a vast number of possible under-lying causes including several ones that re-quire surgical treatment. It is the most common sur-gical emergency, the most common cause for a surgical consultation in the emergency department and the most common cause for non-trauma related hospital admissions. The golden mis-sion statement is to rapidly identify whether the underlying cause requires an urgent or even immediate surgical intervention. However, behind the same cardinal symptom one may encounter harmless or non-urgent problems. By employing diagnostic means cost effectively and with the aim to avoid unnecessary exposure of the patient to X-rays in mind, the challenge remains to identify patients with an indication for emergency surgery from those who suffer from a less serious condition and thus can be treated conservatively and without any pressure of time. Dealing with such a highly complex decision-making process calls for a clinical algorithm. Many publications are available that have scrutinised the different aspects of the initial assessment and the emergency management of acute abdominal pain. How-ever, the large body of evidence seems to miss articles that describe a formally correct priority- and problem-based approach. Clinical algorithms apply to complex disease states such as acute abdominal pain and translate them into one clearly laid out, logically coordinated and systematic overall process. Our intention is to devel-op such an algorithm to approach acute abdominal pain from the surgeon's point of view. Based on daily practice and with reference to available literature, it is the aim of this study to define a work flow that simply summarises all steps in-volved and defines the required decision process in order to form the intellectual basis for an evidence-based clinical algorithm. The result is illustrated as a first draft of such an evidence-based algorithm to allow emergency evaluation of adult patients with acute abdominal pain.     

穿透性心脏损伤急诊室剖胸五例穿透性心脏损伤急诊室剖胸五例

目的探讨在急诊室剖胸对危急心脏穿透伤的疗效。方法在急诊室紧急开胸５例，４例濒于死亡，１例已无生命体征；火器伤２例，锐器伤３例；心脏压塞型２例，失血休克型３例。结果全组死亡３例，存活２例（２／５）；火器伤２例均无存活（０／２），锐器伤２例存活（２／３）；压塞型１例存活（１／２），失血休克型１例存活（１／３）。结论急诊室剖胸是救治危急心脏穿透伤的有效手段，濒于死亡的心脏穿透伤特别是锐器伤部分可能获救     

Pneumothorax in the Emergency Room: personal caseload

The aim of this study was to collect information on the incidence, pathophysiology, treatment and mortality of pneumothorax in the Emergency Room. Pneumothorax is classified as spontaneous (primary, secondary or catamenial) or traumatic (iatrogenic or secondary to a blunt or penetrating chest injury). Between January 2007 and December 2009, 102 patients with pneumothorax were seen in our Emergency Room. Their records were examined and their data collected retrospectively. The type and side of the pneumothorax and age, sex, incidence and mortality were analyzed. The cases, involving 93 males and 9 females, broke down as follows: 68 spontaneous (66.7%), 33 traumatic (32.3%) and one iatrogenic (0.98%). The mean age was 47.3 (range 12-99); the incidence was 0.10%. There were no deaths due to pneumothorax in the Emergency Room. Traumatic pneumothorax was associated with blunt chest trauma, pleural effusion, hemothorax, cranial trauma, fractured collarbone, upper and lower limb fracture, pelvic fracture, vertebral and spinal trauma, sternum fracture and abdominal trauma. Pneumothorax is a common clinical problem. A multidisciplinary approach is essential to reduce the risk of morbidity and mortality. The incidence of pneumothorax in the Emergency Room was similar to that reported in the literature, while mortality data cannot be compared due to the lack of published studies.     

Management of Spontaneously Ruptured Hepatocellular Carcinoma and Hemoperitoneum Manifested as Acute Abdomen in the Emergency Room

Background

Spontaneously ruptured hepatocellular carcinoma (HCC) with hemoperitoneum has a poor prognosis, especially in cases of cirrhosis. Patients usually present to emergency rooms (ERs) with acute abdomen. The aim of the present study was to determine the factors affecting mortality and to compare the prognosis of conservative treatment, transcatheter arterial embolization (TAE), or hepatectomy in these situations.

Methods

Fifty-four patients with spontaneously ruptured HCC diagnosed between January 2004 and August 2010 were enrolled in this retrospective review of clinical data. Grouping by survival or mortality, univariate and multivariate analyses of factors affecting 30-day mortality, and long-term survival were conducted. The outcomes of the various treatments were analyzed.

Results

After primary fluid resuscitation in the ER, 6 of 54 patients underwent conservative treatment. Emergency hepatectomy was performed on 19 patients; TAE was used for 29 patients, 18 of whom received staged hepatectomy thereafter. Poor liver function, prolonged international normalized ratio (INR), and conservative treatment were associated with increased 30-day mortality. Logistic regression analysis of cumulative survival revealed that INR?≥?1.4, multiple intrahepatic HCC, and conservative treatment were related to poorer long-term survival. The patients who received hepatectomy, either immediate or staged after TAE, had higher survival rates of 85.2?% at 30?days and 62.2?% at 1?year.

Conclusions

The treatment of ruptured HCC should be tailored to the individual case. Prolonged survival is possible in patients with preserved liver function through curative liver resection. Emergency physicians, radiologists, and surgeons play essential roles in managing these patients.     

Emergency abdominal surgery in the aged.

The results of 375 emergency abdominal operations in elderly patients over the age of 75 years are presented and discussed in detail. There has been a fourfold increase in the population over the age of 75 years in England and Wales during the 60-year period from 1911 to 1971. The overall mortality of these patients of 31-7 per cent is unrelated to the age of the patient, but appears to be directly related to the severity of the surgical condition and to cardiorespiratory complications. Our approach to these problems is presented and discussed.     

Management of acute abdominal pain: decision making in the accident and emergency department

In the management of patients who present to the accident and emergency department with acute abdominal pain the casualty officer has three options: to treat and discharge, to refer to the out-patient department or to refer for urgent admission. The early management of 512 adults presenting to one accident and emergency department with acute abdominal pain has been prospectively studied to determine the accuracy of the casualty officers' decisions as opposed to diagnostic accuracy. Of the 512 patients, 333 (65%) were discharged home with no further hospital follow-up having been arranged; of these 18 (5%) returned with persistent symptoms and five (2%) were admitted. Of 132 patients referred for urgent admission 113 (85.6%) were either admitted or further investigated and were followed up as out-patients. This study demonstrates a high accuracy of decision making by relatively junior hospital staff in the management of acute abdominal pain.     

Factors contributing to poor post-operative abdominal pain management in adult patients: a review

Post-operative abdominal pain management can be a major issue facing medical and nursing staff in daily clinical practice. Effective pain control reduces post-operative morbidity as well as facilitates rehabilitation and accelerates recovery from surgery. In turn, poor pain control has been shown to alter body metabolic response that can lead to delayed recovery, with subsequent prolonged hospital stay and increased morbidity, and can lead to the development of a chronic pain state.Despite the significant developments in anaesthesia, delivery techniques and analgesia, post-operative abdominal pain management in adult patients remains suboptimal. Achieving effective pain management needs the implementation of an active approach in practice. This approach includes the provision of information and appropriate education tailored to the patients' needs and level of understanding, with the aim of reducing patient anxiety and avoiding unrealistic expectations. In addition, medical and nursing staff should continuously use the appropriate pain assessment tools to evaluate of post-operative pain in the surgical wards. Pain assessment needs to be regarded as the fifth vital sign and recorded on the patients observation chart.Analgesia should be used in a multimodal fashion and “by the clock” according to the patients needs. Moreover, governmental and professional guidelines need to be implemented to establish continuity of care, improve the quality of decision making and reduce unnecessary variations in practiceOverall, there is a need for improved post-operative abdominal pain management in adults to enhance recovery, patient safety and reduce morbidity. This can be achieved with the appropriate education backed up with robust policies and guidelines, supported by up to date evidence.