Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline

BACKGROUND: High-dose transarterial (TA) technique results in high effectiveness of the axillary block. The technique is fast and simple, but does not produce a satisfactory success rate when using the manufacturer's recommended dose of mepivacaine. The multiple nerve stimulation (MNS) technique requires more time and experience. This double-blind study compared effectiveness, safety and the time used to obtain an effective analgesia in 101 patients, having an axillary block by either TA or MNS techniques. METHODS: Mepivacaine with adrenaline (MEPA), 850 mg, was used for the initial block. Five millilitres of 1% solution was injected subcutaneously. In the TA group, 20 mL of 2% solution was injected deep to, and 20 mL superficial to the axillary artery. In the MNS group, four terminal motor nerves were electrolocated in the axilla, and injected with 10 mL each. Analgesia was assessed every 10 min and, when needed, supplemented after 30 min. The block was effective when analgesia was present in all sensory nerve areas distal to the elbow. RESULTS: The MNS group required median 11 min for block performance compared with 8 min for the TA group (P < 0.001). Latency of the initial block was shorter and the frequency of supplemental analgesia lower in the MNS group (median 10 min and 6%) than in the TA group (30 min and 36%, respectively), P < 0.001. All incomplete blocks were successfully supplemented. However, the total time to obtain an effective block was shorter in the MNS group (23 min) than in the TA group (37 min), P < 0.001. Two patients in each group had signs and symptoms of systemic toxicity, the most serious being atrial fibrillation and temporary loss of consciousness in a cardiovascularly medicated patient. The local adverse effects (intravascular injections and haematomas) were fewer in the MNS group, P < 0.001. CONCLUSION: The MNS technique of axillary block by four injections of 10 mL of 2% MEPA produces faster and more extensive block than the TA technique by two injections of 20 mL. Therefore, the MNS technique requires fewer supplementary blocks and results in faster patient readiness for surgery. However, high doses of MEPA may result in dangerous systemic toxic reactions.     

颅脑外伤性迟发性出血的CT诊断

目的：用ＣＴ随访研究颅内迟发性血肿,方法：在２３２例颅脑外伤患者中行ＣＴ随访检查,结果：６１例发现有迟发性颅内出血,其中３８例为原血肿增大或出现新的血肿;８例为对冲伤血肿,１５例为脑挫伤与小量散在出血灶,结论：在外伤病例中,即使开初ＣＴ扫描为阴性者,如病人的临床表现有改变,如症状加重,意识丧失,抽搐等,应立即行ＣＴ复查,对ＣＴ随访的价值及迟发出血的机理也进行了讨论。     

Emergency ventilation using the Combitube in cases of difficult intubation

Summary The esophageal-tracheal Combitube (Sheridan, Argyle, NY) is a new device for emergency intubation, which can be inserted blindly without the use of a laryngoscope. Ventilation is independent of the position of the Combitube in either the esophagus or the trachea, since ventilation is always provided by the tube's double channel. The tracheal channel acts as a conventional endotracheal airway and has an open distal end. The esophageal channel has a blocked distal end, so that together with the inflated distal cuff it acts as an esophageal obturator in cases of esophageal intubation. Perforations at the pharyngeal section direct the airflow to the trachea. At the oropharyngeal section a large elastic balloon is positioned in order to obturate the oral cavity and the nasopharynx. Two patients are described to exemplify the Combitube's clinical use. Both had rapidly enlarging cervical hematomas causing upper airway obstruction and thus requiring immediate intubation. Endotracheal intubation failed because the glottis could not be visualized with a laryngoscope. In both cases the Combitube was applied successfully and adequate ventilation was provided via the Combitube placed esophageally. To better secure each patient's airway, tracheotomy was performed during ventilation without any complications.     

Intramural hematoma of the esophagus caused by minor head injury 6 hours previously

The diagnosis of extensive intramural hematoma of the esophagus due to a bicycle trauma was considerably delayed because symptoms did not develop until 6 h after the accident. This report underscores the importance of a barium meal and computed tomographic (CT) scan in cases of unexplained chest pain, even after minor trauma.     

急性硬膜下血肿预后因素分析

目的 探讨CT征象、GCS评分、瞳孔变化、手术时机、血压、年龄、血糖、血白细胞计数和并发症对96例急性硬膜下血肿手术患者预后因素的影响。方法 对我科96例急性硬膜下血肿手术患者预后影响因素进行回顾性分析。结果 按COS标准，恢复良好46．9％，中度残疾9．4％，重度残疾6．3％，持续性植物生存5．2％，死亡32．2％。结论 CT征象、GCS评分、瞳孔变化、手术时机、血压、年龄、血糖、血白细胞和并发症是评价急性硬膜下血肿预后的可靠指标。及时、正确清除血肿，标准去骨瓣减压，维持正常血压，控制血糖和防治并发症，能有效改善急性硬膜下血肿患者预后，也是降低患者死残率的最有效措施。     

76例产后阴道血肿的临床分析

目的 :探讨减少产后阴道血肿发生的方法。方法 :应用回顾性方法对 76例产后阴道血肿临床资料进行分析。结果 :76例患者急产占 2 7 6 3% ,第二产程延长占 4 6 0 5 % ,血肿发生在会阴左侧切口处及左侧阴道壁占 6 9 73% ,血肿发生时间在产后 2h内占 84 2 1%。结论 :产后阴道血肿的发生与产科质量密切相关     

急性脑肿胀去大骨瓣减压术后迟发性血肿

目的探讨外伤后急性脑肿胀去大骨瓣减压术后迟发性血肿的发病机制及临床表现，以提高该类病人的手术疗效。方法回顾性分析28例急性脑肿胀去大骨瓣减压术后迟发性颅内血肿病人的临床表现。结果外伤后急性脑肿胀去大骨瓣术后迟发性血肿的发生率为19．56％，术区继发硬膜外血肿10．87％。死亡率为32．12％。结论急性脑肿胀去大骨瓣术后迟发性血肿的发生率较高，多见于脑肿胀缓解病例，对术中出现的急性脑膨出和术后病情恶化应考虑到迟发性血肿的可能，早期的诊断是提高疗效的关键。     

急性颅内血肿清除后继发对侧迟发性血肿

目的：急性外伤性颅内血肿清除的术中及术后，如及时发现对侧迟发性血肿并治疗可提高疗效。方法：在术中发生急性脑肿胀时应在对侧钻颅探查或术后病人恶化时行ＣＴ检查。结果：治疗３０例对侧迟发血肿病人其中１０例死亡，手术死亡率为３３．３％。结论：在清除急性外伤性颅内血肿时发生急性脑肿胀或术后病情恶化应想到对侧可能是迟发性血肿形成，宜尽早钻颅探查或复查ＣＴ，早诊早治可改善预后。     

颅骨钻单孔引流治疗慢性硬膜下血肿108例分析

目的：探讨颅骨钻单孔用特制血肿腔冲洗引流管冲洗引流治疗慢性硬膜下血肿的效果。方法：对108例病人进行回颐性分析。结果：治愈106例，随访1～6年无复发。死亡2例，死亡率1．85％。结论：应用颅骨钻单孔，置特制血肿腔冲洗引流管治疗慢性硬膜下血肿，减化了传统钻双孔的手术程序且效果满意。     

迟发性外伤性颅内血肿113例分析

目的总结和分析外伤性迟发性颅内血肿的临床特点及其影像学特征。方法对1995年1月至2003年3月住院治疗的外伤性迟发性颅内血肿患者病历资料进行回顾性分析。结果在同期住院治疗的1574例颅脑损伤患者中,有113例(7.2%)出现迟发性颅内血肿或因迟发性颅内血肿入院手术治疗,术后恢复良好18例(15.9%),中残29例(25.7%),重残25例(22.1%),植物生存17例(15.1%),死亡24例(21.2%)。结论外伤性迟发性颅内血肿有其明确的临床特点和典型的影像学特征,及早发现、及时手术抢救治疗,能显著改善外伤性迟发性颅内血肿的预后。