Interdisziplinäres Polytraumamanagement

Zusammenfassung Jährlich werden rund 8000 polytraumatisierte Patienten in den Kliniken der Bundesrepublik aufgenommen. Insbesondere ein begleitendes Schädel-Hirn-Trauma, ein Abdominal- oder Thoraxtrauma können prognosebestimmend sein. Hypoxie und Hypotonie auf dem Boden eines hämorraghisch-traumatisch bedingten Schockes stehen im Vordergrund. Die Sicherung der Atemwege, eine adäquate Volumentherapie unter Berücksichtigung des Verletzungsmusters, die Schmerztherapie sowie der rasche und schonende Transport in das nächste geeignete Traumazentrum sind die wesentlichen Säulen des heutigen präklinischen Versorgungskonzepts.Die präklinische Versorgung von polytraumatisierten Patienten stellt meist eine besondere Herausforderung für die Einsatzkräfte dar. In einer aktuellen Studie gaben bis zu 21% der befragten Notfallmediziner die präklinische Versorgung von Polytraumatisierten als mit größter persönlicher Angst belegt an. Der vorliegende Artikel geht daher insbesondere auf die aktuellen Algorithmen zur präklinischen Versorgung von polytraumatisierten Patienten ein.     

Neuromuskuläres Monitoring

Berg et al. [4] haben nachgewiesen, dass neuromuskul?re Restblockaden ein unabh?ngiger Risikofaktor für das Auftreten postoperativer pulmonaler Komplikationen sind und somit direkt zu l?ngerem Krankenhausaufenthalt, zus?tzlichen Kosten und erh?hter perioperativer Morbidit?t beitragen. Durch neuromuskul?res Monitoring k?nnen Restblockaden rechtzeitig erkannt und therapiert werden. Darüber hinaus liefert diese überwachungsmethode auch wichtige Informationen über den Wirkungseintritt von Muskelrelaxanzien und deren intraoperativen Verlauf. Voraussetzung hierzu ist jedoch eine sachgerechte Anwendung der Technik und eine richtige Interpretation der Messergebnisse. Im folgenden Beitrag wird auf wesentliche Grundlagen des neuromuskul?ren Monitorings eingegangen, sowie die klinische Anwendung dieser Methode beschrieben.

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Neuromuskuläres Monitoring

The effect of muscle relaxants varies among people and the extent, the duration and recovery from the neuromuscular block varies. Clinical tests cannot determine the effect of muscle relaxants which is only possible with neuromuscular monitoring. The relaxometry procedure measures the muscular response to electrical stimulation of the corresponding motor nerve and the adductor pollicis muscle is mostly used; however, this muscle is not representative for other muscle groups, such as the muscles of the larynx and diaphragm. The muscles of the larynx and diaphragm are more resistant against nondepolarizing muscle relaxants than the adductor pollicis muscle. The train of four (TOF) is used at the beginning of surgery for monitoring of the optimal time for tracheal intubation; moreover, the TOF is used during surgery for monitoring of the muscle blockade and at the end of surgery for monitoring recovery. Monitoring of deep muscular blockades, however, is only possible with the posttetanic count (PTC) when there are no TOF counts. The PTC allows repetition and higher doses of muscle relaxants during abdominal surgery; therefore, conditions for surgery are optimal and cumulation of muscle relaxants is avoided.     

Kardiovaskuläres Tissue-Engineering

With the advent and progressive development of decellularization technologies the concept of cardiovascular tissue engineering (CVTE) has become clinical reality in the case of heart valves. Both preclinical and clinical studies have demonstrated the value of this concept for pulmonary valve replacement; however, in the hemodynamically challenging aortic position, proof of feasibility has only recently emerged from preclinical studies and initial clinical series. An autologous in vitro re-endothelialization by reseeding and bioreactor cultivation has proven to be superior; however, this process is deemed barely feasible for a broad clinical use. Hence, alternative strategies aiming at a modification of the implant biointerface are being investigated, e.g. by bioactive surface coating, in order to inhibit adverse remodeling in vivo. Against this background, increasing attention will be concentrated on the development of novel animal models including genetically modified strains. In contrast, the development of a clinically applicable tissue engineered myocardial tissue (TEMT) is still out of reach. Currently, no protocol exists for the isolation, expansion and three-dimensional (3D) reconstruction of suitable cells to form a clinically useful myocardial tissue substitute, which contrasts with the recent experimental success achieved by using embryonic or induced pluripotent stem cells. However, decellularization has facilitated a scientific breakthrough in terms of providing an organotypic 3D matrix with an intact native vascular network derived from a donor organ. Beside the inductive signals inherent to such a matrix, further signals, such as biomechanical cues or electrophysiological stimuli may be necessary for a successful construction of a TEMT. The integration of a decellularized myocardial matrix with biomechanical and electrophysiological stimuli may favorably impact on the cell differentiation capacity and prove to be a valuable tool for tissue engineering of functional myocardium.     

Femoroacetabuläres Impingement

Zusammenfassung Während die Ursache der Gelenkschädigung bei der Hüftdysplasie auf eine überhöhte axiale Belastung der Gelenkpfanne klar zurückgeführt werden kann, ist die exakte Ursache der idiopathischen Koxarthrose bis heute nicht geklärt. Basierend auf der Entwicklung einer chirurgischen Technik zur gefahrlosen chirurgischen Luxation der Hüfte und der damit verbundenen Möglichkeit der intraoperativen Gelenkbeurteilung, fanden wir eine bewegungsinduzierte Schädigung, die peripher am Acetabulumrand beginnt und nach zentral fortschreitet. Dieses sog. femoroacetabuläre Impingement (FAI), welches durch eine vermehrte acetabuläre Überdachung und/oder fehlende Sphärizität des Femurkopfes zu einem Anschlagen bzw. Einpressen des Femurkopfes in die Gelenkpfanne führt, verursacht eine Schädigung des Labrum und/oder des Gelenkknorpels.Häufig kommt bei den bereits in der 2. und 3. Lebensdekade symptomatisch werdenden Patienten (Leistenschmerzen, reduzierte Innenrotation) eine vermehrte sportliche Aktivität hinzu. Basierend darauf, ob die acetabuläre oder femorale Pathologie dominiert, werden zwei verschiedene Typen des FAI, das Pincer- (Beißzangen-) und das Cam- (Nockenwellen-)FAI unterschieden. Neben diesen ossären Alterationen tragen auch eine supraphysiologische Beweglichkeit sowie eine Überbeanspruchung zum FAI bei. Das Impingement-Konzept hat zu einer Reihe neuer, mehrheitlich intrakapsulärer Chirurgieansätze geführt.     

Varikozele und pubertäres Hodenwachstum

BACKGROUND: We prospectively assessed male students in the 4th and 8th forms to see whether varicoceles affect testicular growth. PARTICIPANTS AND METHODS: Ultrasound measurements were done in 778 boys to define testicular size according to the different pubertal stages. Seven hundred boys had a left or bilateral varicocele; 257 children and 287 adolescents with unilateral varicoceles were assessed for testicular size discrepancies in relationship to the varicocele size and the Doppler grades of venous reflux in the upright and supine positions. RESULTS: Rapid testicular growth occurred at puberty. By comparing the frequencies and extent of ipsilateral growth failures in adolescents, we noted significant differences among the varicocele grades. A volume loss of >/=15% was associated with the higher varicocele grades and the reflux grades in the supine position. CONCLUSION: Varicoceles may impair testicular growth at puberty. The severity of volume loss depends on the varicocele size and the related alterations in circulatory flow.     

Primäres Adenokarzinom der Samenblasen

Primary malignancies of the seminal vesicles are extremely rare. They must be strictly differentiated from surrounding malignancies that may infiltrate the seminal vesicles from outside (e.g. prostate, rectum, and bladder carcinoma). MEDLINE and CANCERLIT review showed about 50 documented cases of primary seminal vesicle carcinoma so far worldwide in men between 19 and 90 years of age. Early diagnosis may be difficult due to lack of specific symptoms. Especially with a history of voiding dysfunction, haemospermia and/or haematuria, investigators should consider it. Primary diagnostic steps include digital rectal examination, transrectal ultrasound, and transrectal biopsy of the tumour. Additionally, CT and MRT scans show tumour masses corresponding to the seminal vesicles. Adenocarcinoma of seminal vesicles shows no expression of prostate-specific antigen or prostate-specific acid phosphatase, but there may be expression of carcinoembryonic antigen and cancer antigen 125. Radical surgery including radical prostatectomy and/or cystoprostatectomy including pelvic lymph node dissection offers a curative treatment pathway. Adjuvant or inductive medical treatment is of unproven worth, but a combination of hormonal deprivation and radiotherapy seems to be more effective than any chemotherapy.     

Intraartikuläres Osteoidosteom des Sprunggelenks

Osteoid osteoma is a benign osteoblastic tumoral lesion. It is seldom intraarticularly localized and presents nonspecific signs and symptoms, such as swelling, slight warmth, and nocturnal pain. Because of unusual clinical findings and the frequent absence of typical bone sclerosis, diagnosis often takes longer than for extraarticular osteoid osteoma. Complete arthroscopic en bloc excision of the lesion is the treatment of choice, offering complete relief of symptoms following surgery. Extirpation of the nidus may prevent damage to the articular surface.     

Hepatozelluläres Karzinom und Cholangiokarzinom

Hepatocellular carcinoma and cholangiocarcinoma are relatively rare tumors of the gastrointestinal tract in western Europe but their incidence has been increased in recent years. Newly diagnosed intrahepatic lesions or intrahepatic cholestasis require extensive laboratory tests and imaging studies in order to confirm the diagnosis of hepatocellular carcinoma, intrahepatic or extrahepatic cholangiocarcinoma. The treatment options range from liver resection or liver transplantation to conservative measures (in cases of non-resectable lesions). This review article aims to provide an overview on the diagnostic options and the subsequent treatment.     

Femoroazetabuläres Impingement bei Sportlern

Femoroacetabular impingement (FAI) and its therapy has gained importance in the last decade and several studies could show that if untreated it may lead to osteoarthritis of the hip joint. In this article an overview of the pathology of FAI, the diagnosis and treatment options are presented. A closer look is taken at the treatment of elite athletes regarding the different techniques. The first own clinical and radiological results of 91 patients treated by the arthroscopically-assisted anterior mini-open approach are presented with very good results and significant postoperative improvement regarding the hip injury and osteoarthritis outcome score (HOOS), the Western Ontario and McMasters University (WOMAC) osteoarthritis index and the University of California Los Angeles (UCLA) activity score, as well as alpha angle correction. This technique which is poorly represented in the literature can be used as a treatment option for FAI. The rehabilitation program is comparable to hip arthroscopy.     

Primäres Urethralcarcinom mit priapismusähnlichen Folgen

Ohne Zusammenfassung     

Neuromuskuläres Defizit bei chronischer Sprunggelenkinstabilität

The peroneal reaction time (PRT) is used in the assessment of neuromuscular deficits in chronic functional ankle instability. Powered by the Editorial Manager® and Preprint Manager® from Aries Systems Corporation the present study was conducted to determine the PRT in a large collective of patients with chronic ankle instability because it is unclear if this parameter of neuromuscular deficit is prolonged. In this study 186 patients underwent a diagnostic algorithm consisting of anamnesis, clinical examination, X-ray and determination of the PRT on a tilting platform. A prolonged PRT as a manifestation of a neuromuscular deficit could be detected in the majority of the patients (n?=?143, 77?%). Comparing the affected and healthy legs 77 patients (41?%) showed a significant difference in talar shift (p?=?0.002) and talar tilt (p?=?0.04) in the radiological stress views. Of these 77 patients only 15 (8?%) showed radiological evidence of a mechanical problem. As a consequence of recurring ankle sprains a post-traumatic deficit in proprioception has to be expected in most cases. In general a conservative therapy approach should be followed including specific training to improve neuromuscular and proprioceptive deficits.     

Pterygo-maxilläres Basalfibroid bei freiem Nasenrachen

Langenbeck's Archives of Surgery - Es werden zwei operierte pterygo-maxilläre Basalfibroide mitgeteilt, von denen einer den Nasenrachen völlig frei ließ und sich lediglich nach...     

Biphasisches primäres Synovialsarkom der Niere

Primary synovial sarcoma of the kidney is a rare neoplasm, which was first described by Argani et al. in 2000. We report a case of a 47-year-old man presenting with a renal mass of 11.7x9.3x8.1 cm size and a caval thrombus, which was classified as a biphasic differentiated spindle cell tumor. Fluorescence in situ hybridization (FISH) revealed a translocation t(X;18), specific for synovial sarcoma. In younger patients presenting with spindle cell-like renal tumors, a primary synovial sarcoma should be considered as a differential diagnosis.