Fulminante Lungenembolie nach Sectio caesarea

On the first day after an uneventful emergence caesarean section a 36-year-old woman developed circulatory collapse requiring cardiopulmonary resuscitation for 15 minutes. After resuscitation the patient remained haemodynamically unstable and was clinically highly suspected to suffer from fulminant pulmonary embolism. In this situation the physicians caring for the patient decided to perform a surgical pulmonary embolectomy without previous diagnostic workup. Massive emboli were removed from both pulmonary arteries. Postoperatively the patient recovered and was transferred to a rehabilitation center without severe cerebral sequelae.     

Zugangswege für die Medikamentenapplikation bei Herzkreislaufstillstand

Selecting a route for drug administration during CPR requires consideration of the speed with which access can be obtained, the technical difficulties involved in performing the procedure, the associated risk of complications, delays in drug delivery to the central circulation, and the duration of effective drug levels following injection. The peripheral venous route is the safest method, and drug delivery can be enhanced by a fluid bolus after injection of the medication. The circulation time is shortest after central venous injection, but there is some risk of complications. The femoral route is associated with a high incidence of unsuccessful catherization. The endotracheal tube provides an accessible route for administration of most drugs, but peak concentrations are lower than those obtained by other routes. While the results are almost the same as an intravenous injection, the intraosseous route is currently underrepresented in clinical practice. This method must not only be considered in pediatric patients, but in adult patients as well.     

Studien in der Notfallmedizin

Clinical studies in emergency medicine are often difficult to perform. Besides ethical issues, the high number of patients required to conduct conclusive clinical trials represents a major problem in the scientific evaluation of important questions in emergency medicine. Furthermore, there is often less or no financial support from the industry for such studies because new and improved therapies may not always lead to an adequate and immediate profit. Thus, only very few therapeutic options in emergency medicine have actually been evaluated scientifically and confirmed by conclusive clinical trials. To further improve outcome of patients in this area in the future, a high number of clinical studies in emergency medicine is required. Because many patients have to be enrolled in such studies, this is only possible through the use of study networks, where many centres actively participate. Although studies in emergency medicine are not easy to perform, in the interest of our patients, they are absolutely mandatory, and they are feasible.     

Erfolgreiche lokale Katheterfragmentation und Thrombolyse bei akuter Lungenembolie in der frühen postoperativen Phase nach Pankreaskopfresektion

Pulmonary embolism in the early postoperative period is characterized by high morbidity and mortality. Systemic application of thrombolytic agents during this time is contraindicated; operative thrombectomy also has a high mortality rate. We report a case of successful local lysis in combination with catheter fragmentation of a massive two-sided pulmonary embolism diagnosed on the 4th postoperative day after pylorus-preserving duodenopancreatectomy for distal carcinoma of the common bile duct. Thrombolysis was performed in three sessions by a combination of catheter-supported interventional fragmentation of the thrombus with local rt-PA lysis. There were no bleeding complications or disturbances of anastomotic healing. The patient was discharged from the hospital on the 23rd postoperative day after changing anticoagulation to a vitamin K antagonist. The case presented demonstrates the possibility of local lysis in combination with interventional methods as a therapeutic option for pulmonary embolism in the early postoperative period as an alternative to surgical strategies.     

Ethische Konflikte während der Anästhesie „Do not resuscitate”-Verfügungen im Operationssaal

Patients have the right to make decisions concerning their health care. The right to consent to or refuse treatment is based on the ethical principle of autonomy. Respecting a patient’s autonomy has emerged as one of the leading principles in medical ethics in the last years. In the United States, the Patient Self-Determination Act of 1991 stated that all patients admitted to hospital have to be informed about their right to prepare advance directives and to refuse life-prolonging treatment. Do-not-resuscitate (DNR) orders have been established to provide a mechanism for withholding specific resuscitative therapies in the event of cardiac arrest. Patients may write DNR orders to express in advance their preferences at a time when they are capable of making informed decisions. Terminally ill patients may need palliative surgical interventions to relieve pain or facilitate care. In patients with DNR orders undergoing anaesthesia and surgical procedures, the DNR status in the operating room is increasingly a matter of ethical conflict. Anaesthetic care virtually always implies the provision of resuscitative measures if necessary. Interventions like intubation, mechanical ventilation, or administration of vasoactive drugs may be regarded as a part of resuscitative efforts. There is a remarkable lack of consistency in policies and practices in hospitals regarding interpretation of DNR orders during the perioperative period. Considering policies automatically suspending DNR orders prior to anaesthetic care, the American Society of Anesthesiologists (ASA) in 1993 introduced ”Ethical guidelines for the anesthesia care of patients with do not resuscitate orders or other directives that limit treatment”. To address a patient’s right to self-determination in a responsible and ethical way, the ASA recommends explicitly discussing with the patient all limitations of therapeutic interventions. A list of relevant items that should be considered, like defibrillation and chest compression, but also blood product transfusion or the administration of antibiotics, has been provided by the ASA. These statements can provide some order to an increasing state of uncertainty, but guidelines might also be regarded as imposing restrictions that compromise the anaesthesiologist’s autonomy. I believe that defining accepted and refused interventions in advance is not an appropriate approach to DNR orders during anaesthesia and surgery, as it will be difficult to find a definition of what constitutes resuscitation in this context. Communication with the patient and exchange of information are essential factors promoting ethical decisions. Knowing the individual patient’s preferences and fears, a more suitable approach seems to be the perioperative suspension of the DNR order for a limited period of time, with the assurance that therapeutic procedures instituted during surgery will be discontinued postoperatively in reconsideration of the DNR order and if the underlying disease process turns out to be non-reversible.     

Die präklinische Blutgasanalyse Teil 1: Der Stellenwert der präklinischen Blutgasanalyse

Prehospital blood gas analysis is a new method in out-of-hospital emergency care. In a prospective pilot study we evaluated the feasibility of prehospital compensation of severe acidosis relying on different monitoring systems to evaluate patients oxygen, carbon dioxide or acid-base status, respectively. Methods: With the help of arterial blood gas checks taken at the site of the emergency, the acid base status of patients undergoing out of hospital cardiopulmonary resuscitation was analysed. The values derived from the first arterial puncture were used to determine the presence and the type of acidosis. The data of the arterial blood gas checks were set into relation with the time elapsed since the beginning of resuscitation and they were compared with end-tidal CO₂. Results: During the observation period 26 blood gas analyses from patients who had out-of-hospital resuscitation because of cardiac arrest were done. Twenty three patients had severe acidosis (pH range <6.9 to 7.31), one had alkalosis (pH 7.51). Only two had an arterial pH within normal range. The pCO₂ was variable (range: 24 to 97 mm Hg). The correlation of pH with time from the beginning of resuscitation to arterial puncture was poor (r=0.407, p<0.05). There was no correlation between pH and BE (r=0.267) or pH and pCO₂, (r=0.016) respectively. Prehospital capnometry had a poor correlation with arterial pCO₂ in most emergeny patients. Only patients with respiratory disturbances of extrapulmonary origin showed a good correlation between end-tidal CO₂ and the arterial pCO₂. In severely ill patients the arterio-alveolar CO₂-difference was unexpectedly high (>15 mm Hg). In four patients resuscitation was not sucessful until compensation of an unexpectedly severe acidosis based upon the findings from blood-gas analysis had been performed. Conclusions: Arterial blood gas analysis proved to be helpful in the optimal management of out of hospital cardiac arrest. The incidence of severe acidosis in patients undergoing cardiopulmonary resuscitation was 80%. The probability of developing acidosis was found to increase slightly depending on the time elapsed since the beginning of CPR. The application of a calculated buffering of acidosis with sodium bicarbonate showed a good outcome in selected cases. In emergency patients alternative methods fail to detect severe disturbances of the patients oxygen and/or carbon dioxide status and the acid-base balance. Management of prehospital cardiac arrest could be optimized by the routine use of blood gas analysis.     

Fettembolie

Zusammenfassung Die extrathorakale Kompression des Herzens im Rahmen der Reanimation ist eine einfache und suffiziente Methode, die seit Jahren etabliert ist. Immer wieder wurde aber die Frage nach m?glichen Komplikationen dieser mit gro?er Kraft durchgeführten Ma?nahme gestellt. Neben Frakturen im Bereich des Thorax, sowie Verletzungen innerer Organe, vorwiegend Herz, Leber und Milz, wird in diesem Zusammenhang h?ufig auch die Fettembolie, vor allem der Lungen aber auch anderer Organe, genannt. Zu deren Entstehung gibt es unterschiedliche Theorien. Diese übersicht berücksichtigt die wesentlichen Ver?ffentlichungen der letzten Jahrzehnte zu diesem Thema. Die Fettembolie wurde vor allem in pathologischen und unfallchirurgischen Studien untersucht. Die tats?chliche Inzidenz der Fettembolie bei Traumen, der operativen Versorgung von langen R?hrenknochen, Schockzust?nden allgemein und nach Reanimationen scheint hoch zu sein. Sie scheint allerdings klinisch selten manifest zu werden. In den meisten F?llen nach (erfolgloser) Reanimation ist die in der pathologischen Untersuchung gefundene Auspr?gung der Fettembolie gering bis mittelgradig. Aufgrund des Fehlens entsprechender Studien sind überlegungen über die Bedeutung von Fettembolien im artifiziellen Kreislauf w?hrend einer Reanimation spekulativ.      

Kammerflimmern/-flattern: Prädiktoren für den Defibrillationserfolg?

Although electrical defibrillation remains the method of choice for treatment of ventricular fibrillation, repeated defibrillation attempts can lead to myocardial damage and consequently deterioration of the patient's outlook for survival. In situations involving prehospital resuscitation,measurements of the coronary perfusion pressure and end-expiratory CO₂ concentration are not suited for optimizing the effectiveness of defibrillation.Hence new noninvasive parameters are being sought to detect the appropriate point in time for defibrillation. Signal analysis of surface EKG enables determination of amplitude and frequency parameters whose value as predictors of successful defibrillation is presented in this study.Defibrillators of the future could decide the optimal point in time for defibrillation themselves.     

Erstversorgung, Reanimation und Transport von Neugeborenen

The primary care of neonate poses a particular challenge to those unpracticed in administering first aid. In most cases it suffices to dry off the newborn child after birth, stimulate respiration, and provide warm towels. Expert measures are necessary for a minority of full-term neonates, and for premature infants this need increases in direct relation to the degree of immaturity. The international Liaison Committee on Resuscitation (ILCOR) has developed internationally valid guidelines. These recommendations are not usually based on data from controlled studies but rather on currently recognized experience and teaching theory. Well-trained personnel should be available during every delivery to provide basic care of neonates. For full-scale resuscitation measures, a specialized team is indispensable. The subsequent transport to a clinic represents a strain on the neonate and is associated with special risks. This report presents the ILCOR recommendations and clinical/practical aspects of transporting a newborn child.     

Alternative Beatmungstechniken: IPPV, CPAP oder O2-Insufflation

Animal experiments indicate that there are advantages of nonphasic artificial respiration over conventional methods.These advantages apply to less traumatization of the lungs, better ventilation with improved oxygenation,CO₂ elimination, and improvement of systemic and pulmonary hemodynamics. Nevertheless, research is still necessary on alternative strategies for artificial respiration during cardiopulmonary resuscitation and on continuous positive airway pressure and transtracheal oxygen insufflation. In future, dynamic computed tomography could assist in visualizing pulmonary ventilation during resuscitation.     

Akute klinische Schlaganfallbehandlung

Stroke is an emergency. Treatment must begin as soon as possible because significant sustained neurological improvement has been demonstrated when thrombolytic treatment, mainly with recombined tissue plasminogen activator (rtPA) is initiated within the first hours of stroke onset. On the other hand in the acute phase of stroke it is critical that patients get adequate management for the prevention of early complications. Management of the acute phase of stroke is the target of this article. Preclinically started treatment must be continued in the neurological emergency unit. Clinical examination is followed by technical investigations: cerebral computer tomography (CCT) is the most useful radiological investigation in the acute phase. It allows to distinguish between ischemia and hemorrhagic lesions and also to rule out nonstroke brain conditions. Multimodal magnetic resonance imaging (mMRI) may provide data on viable versus irreversibly damaged tissue. Sufficient stroke treatment is based on well managed in-hospital infrastructure. Thrombolysis is the only causative treatment of stroke in selected patients. Complications of acute stroke comprise changes of blood pressure with hemodynamically relevant effects on cerebral perfusion pressure, acute post- ischemic brain edema, and intracerebral bleedings.     

Erfahrungen mit dem Einsatz eines potentiell temporären Vena cava-Filters beim mehrfachverletzten Patienten

Zusammenfassung. Einleitung: In Europa existieren nur wenig Erfahrungen mit der Einlage von Cava-Filtern bei schwerverletzten Patienten. Besonders nach Verletzungen des Beckens, der Wirbels?ule und nach Frakturen der unteren Extremit?t weisen mehrfachverletzte Patienten ein erh?htes Thromboserisiko mit Gefahr einer Lungenembolie (LE) auf. Eine zus?tzliche Problematik findet sich bei Patienten mit schwerem Sch?del-Hirn-Trauma (SHT), bei denen eine Kontraindikation zur Anticoagulation besteht. Die vorliegende Arbeit zeigt unsere Erfahrungen mit einem tempor?ren Cava-Filter (Günter-Tulip) bei polytraumatisierten Patienten mit hohem Thrombose- bzw. Embolierisiko und gleichzeitiger Kontraindikation zur Anticoagulation. Methode: 24 konsekutive Patienten mit Mehrfachverletztung die zwischen September 1996 und M?rz 2000 einen Cava-Filter erhalten haben wurden im Sinne einer konsekutiven Beobachtungsstudie analysiert. Die Einlage des Filters erfolgte percutan über die V. femoralis (n = 20) und V. jugularis (n = 4). Die 24 Patienten wiesen einen durchschnittlichen Injury Severity Score (ISS) von 35,1 ± 2,01 auf und waren im Schnitt 41,4 ± 2,89 Jahre alt. Die h?ufigsten Begleitverletzungen waren ein schweres SHT (n = 17) bzw. eine Beckenringverletzung (n = 19). Die Einlage erfolgte bei 17 Patienten prophylaktisch, bei 3 Patienten nach der Diagnose von Lungenembolien und bei 4 Patienten nach der Diagnose einer tiefen Beinvenenthrombose. Ergebnisse: Die Einlage des Filters war bei allen Patienten komplikationslos. Nach der Schirmeinlage wurde klinisch bei keinem Patienten eine Lungenembolie diagnostiziert. Als Komplikation trat bei einem Patienten (1/24 = 4,2 %) eine Cavathrombose auf. Schlussfolgerung: Die Einlage eines Cava-Schirms zur Prophylaxe von Lungenembolien ist bei polytraumatisierten Patienten, die u. a. wegen eines SHT nicht anticoaguliert werden k?nnen, ein sicheres und effizientes Verfahren mit geringer Komplikationsrate.      

Notärzte im Umgang mit psychisch belastenden Einsatzsituationen

Reactions of 20 physicians to more than 260 situations of cardiopulmonary resuscitations were examined using a retrospective study of their emotions and communication pattern. Coping strategies of physician's vary: Young physicians show a pattern of emotional denial whilst being active in their resus-citation behaviour. More experienced doctors tend to deny less. Physicians with a history of recent loss seem to be reluctant to cope emotionally. Discussing the situation seems to improve coping behaviour. Active behaviour during the emergency seems to result in relieve for a short time, however, long term coping seems to be impaired. In our data we could identify variables which make coping more difficult to achieve. Amongst others these were age and experience of the physician, maritial status and a history of recent loss. Younger, less experienced physicians and those with recent losses seem to be in need of support. Suggestions to improve the situation of the emergency physician and the team are made with special regards to the time after the emergency and supervision.     

Platten- und Schraubenosteosynthese bei Femurschaftfrakturen Retrospektive Studie von 500 Femurschaftfrakturen

The authors collected 500 cases of breaks of the thighbone shaft which were treated using osteosynthesis with screws, between 1st January 1992 and 31st of December 1996 at the Department for Traumatology of the University Medical Center in Ljubljana. Most patients were male (70.6%), the average age was 36.6 years, and the majority of patients had been injured in traffic accidents. In 50% of cases, only the thighbone was broken, the rest had suffered multiple injuries, or were polytraumatised. Their stay in hospital averaged 17 days, while the average time to union was 21 weeks. In most cases (85%), treatment proceeded with no complications. Chronical post-traumatic osteitis occurred in 9 of the patients with open breaks (1.8%), and only in 2 patients (0.4%) with closed breaks, which is within the limits of tolerance. With respect to our experience and results with osteosynthesis with plates and screws in the thighbone shaft, we believe that the mentioned method is good and gives results which are comparable to those achieved using other methods.     

Die Therapie des Harnleitertumors

Nephroureterectomy is the standard treatment of tumors in the upper and middle third of the ureter. Whereas, resection of the distal ureter and uretercystoneostomy is the treatment of choice of tumors in the lower third, as long as there is enough renal function which is worthwhile to be preserved. Lymphadenectomy should be performed in all patients suspicious for invasion of the ureteral wall since already 10% of patients with pT1 and pT2 tumors will present with metastases to the lymphnodes. In case of functional or anatomic single kidney therapy has to be adapted to the patient and tumor appropriately. Endoscopic resection, partial or complete resection of the ureter with substitution by ileum or autotransplantation with pyelovesicostomy are the operative options. Elective endoscopic treatment of ureteral tumors should be done in patients with G1 tumors only. However, the recurrence rate is as high as 30 to 60% and the mean interval to recurrence is about 9 months. Regular followup by means of cytology and endoscopy is mandatory. Laparoscopic nephroureterectomy is still a experimental treatment at present time and should be not considered in the treatment of ureteral tumors because of the complexity of the procedure and the risk of tumor spillage.     

Diagnostik und Therapie des Hypothenar-Hammer-Syndroms

Zusammenfassung. Arterienverletzungen als direkte Traumafolge führen meist zur Blutung oder Isch?mie. Im Bereich der durch 2 Arterien versorgten Hand kann die akute Isch?mie fehlen. Das Hypothenar-Hammer-Syndrom stellt einen Verschlu? der distalen A. ulnaris als Folge eines Traumas dar. Abh?ngig von der Verletzungsart ist der klinische Beginn meist schleichend und erst eine gezielte duplexsonographische oder angiographische Untersuchung führen zur Diagnose. Bew?hrte Therapieempfehlungen gibt es nicht. Die Diagnostik des Verschlu? der Arteria ulnaris als Unfallfolge ist für den Patienten wichtig und macht einen Therapieansatz erst m?glich.      

Isolated traumatic rupture of the subscapular muscle tendon as an adolescent injury

Introduction. Until now no case of a traumatic tear of the subascapularis muscle in children was described in the German speaking literature. Using the example of 2 cases of a 12 and 14 year boys youth history, clinic, diagnostics and therapy will be presented. Methods. The accident happened in extension and external rotation of the arm without dislocation. Beside the complete tear of the SCP-tendon in one case an accompanying expanded humeral flake fracture at the minor tuberosity was found. Under protection of the epiphysis line the refixation was performed using suture anchors. Results. The post-operative control after 12 months showed a complete tendon healing, no arthritis or delayed bony ingrowth with return to full activity. Conclusion. Isolated traumatic SCP-tears can be occur also in young patients. As major consequence, it is necessary to perform a thorough clinical examination with additional apparative diagnostics (Sonography, MRI). This way, this rare but important lesion can be detected early and lead to adequate surgery without any delay.