山羊血浆TNF与MODS的关系

在山羊ＭＯＤＳ的模型上，观察了血浆ＴＮＦ与ＭＯＤＳ的关系，３２只山羊分为三组：失血性休克组（Ｈ）；门静脉毒素血症组（Ｅ）；失血性休克＋内毒素血症组（Ｍ）。结果表明，三组动物血浆ＴＮＦ均见升高，Ｍ组最明显。动物死亡率及ＭＯＤＳ的发生率也是Ｍ组最高。可以认为ＴＮＦ持续升高导致ＭＯＤ发生发展的重要因素之一。     

Post-traumatic osteomyelitis

Summary Osteomyelitis is one of the most severe complications that can arise following operative treatment of bone. It requires a long-term treatment. The patient can never be sure that it heals completely. The pathophysiology depends on: (1) the extent of soft tissue damage and impairment of blood supply; (2) inoculation of bacterial flora; (3) the instability of the fracture area; and (4) the general defensive condition of the organism. The symptoms of acute osteomyelitis are those of acute inflammation. They appear 1 week to 3 months after operation. The diagnosis can only be made on clinical examination by an experienced surgeon. X-Ray findings are lacking. The treatment of acute osteomyelitis involves debridement of soft tissue and bone sequesters, refixation of the fragments, most often by means of an external fixator, and suction drainage or wet dressing. The reconstruction of the bone is done in a second step. The cancellous bone grafting is performed from a medial approach. Closure of the soft tissue follows.In the case of chronic osteomyelitis scarring, fistulas and muddy secretion are present. The function of the bone is disturbed. X-Ray examination shows loosening of the metal and failing structure of the bone. In this case too, the first step is the debridement of soft tissue and bone. All the metal inside is removed. Stabilization is achieved by means of an external fixator. Once the fracture area has been cleaned, cancellous bone grafting is done once, twice, or even more frequently. For wound closure it is necessary to rotate muscle groups, to cover the bone with dermatomic skin, or to use microvascular flaps. A good blood supply to the soft tissue is essential for bone healing. Especially in the lower leg there is a wide range of indications for free transplantation of microvascular flaps. Reconstruction of long bony defects can then be achieved by means of a fibula pro tibia operation or corticocancellous bone grafting. Antibiotics are worthwhile as a supplement to the surgical treatment, but can never replace it.

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Zusammenfassung Trotz aller hygienischer Maßnahmen, Kenntnissen der Pathophysiologie und Sorgfalt des Operateurs sowie technischer Einrichtungen der Operationssäle ist die posttraumatische Osteomyelitis weiter eine quantitativ beachtliche und qualitativ belastende Komplikation. Die entscheidenden pathogenetischen Faktoren sind: 1. Ausmaß der Zerstörung des Weichteilgewebes und der Blutzufuhr. 2. Keimbesetzung der Wunde. 3. Instabilität der Fraktur. 4. Allgemeine Abwehrlage des Organismus. Diese Faktoren müssen im einzelnen durch die Therapie eliminiert werden.

     

Surgical treatment of injuries of the thoracolumbar transition--3: Follow-up examination. Results of a prospective multi-center study by the "Spinal" Study Group of the German Society of Trauma Surgery

OBJECTIVES: Prospective, multicenter study addressing late results after operative treatment of acute thoracolumbar spinal injuries. METHODS: 682 patients (T10-L2) were included and 372 (80%) were postoperatively followed for 2 1/4 years (4-61 months). RESULTS: Comparing the initially included patients (n = 682) with the study group (n = 372), no differences were observed and results were assumed to be representative. A C-type lesion or polytrauma significantly prolonged the hospital stay. The method of operative treatment did not affect the length of the rehabilitation period. Neurological improvement was observed in 3 out of 7 patients with complete, and in 44 out of 64 (69%) with incomplete lesion. The operative method did not affect the improvement rate. The physical capacity significantly decreased. After a mean of 1/2 year of disability only 71% returned to work. 48% returned to their preoperative physical level. The mean Hannover Spine Score was 68 points (preoperative 94, p < 0.001), indicating permanent impairment of function. The angle-stable internal fixator was superior in restoration of spinal alignment and best radiological results were noted after combined stabilization. Posterior stabilization lead to high re-kyphosing. No correlations between radiologic and clinical parameters were observed. CONCLUSIONS: All treatment methods under study were appropriate for achieving comparable clinical and functional outcome. The internal fixator is superior in restoration of the spinal alignment. Best radiological outcome is achieved by combined stabilization. Merely by direct reconstruction of the anterior column the postoperative re-kyphosing is prevented and a gain in segmental angle is achieved.     

Krankenhausnotaufnahme als kritische Schnittstelle beim MANV

Background

The emergency department is a decisive part of the emergency treatment sequence which has to operate even under extraordinary circumstances. With the experiences of the Love Parade 2010 the planning and reaction to a mass casualty incident are described and discussed.

Methods

To estimate the burden on the emergency departments the patient ICD data of the four hospitals with the highest workload were used to assign priorities to the patients by the Manchester triage system and to determine the necessity of emergency room treatment. The results, the special problems and the solutions were evaluated in a qualified discussion with the emergency departments and paramedics. The result is a qualitative and quantitative workload profile of the emergency departments.

Results

The 4 hospitals treated a total of 388?patients and the number of out-patients treated in each hospital was directly correlated to the distance from the mass incident and the highest workload arose shortly after the incident. With greater distances from the incident a higher proportion of in-patients were admitted and the highest workload occurred later. The key figures for capacity planning are presented and the main problems are discussed.

Conclusions

Emergency departments demand a focused planning for mass casualty incidents and the central admission site is the focal point. The measures installed proved to be adequate to control planned and unplanned patient flow and to provide professional medical treatment.     

Loveparade 2010 Duisburg �C klinische Erfahrungen in Vorbereitung und Versorgung

Background

Tragic incidents at the 2010 Love Parade attracted significant public attention. As the frequency of similar events increases, more hospitals and practitioners will face the necessities of planning and response to unforeseeable occurrences. Obligatory guidelines for physicians do not exist, so that essential aspects are repeatedly discussed for each new event. This paper summarizes the experience of hospitals and emergency departments and draws conclusions, allowing recommendations for reasonable proposals for hospitals and practitioners.

Methods and material

A structured analysis of data concerning planning, patient flow and injury statistics led to a profile determining personnel, rooms and material which have to be provided by the hospitals. In a consensus conference afterwards and personal interviews with clinical coordinators the preparation of hospitals was evaluated to separate reasonable from needless efforts.

Results

We describe various measures concerning staff, logistics and rooms from the viewpoint of actual application. Reasonable measures for preparation and management of mass panic are analysed and described in detail. Problems are explained and solutions discussed. The result is a qualitative catalogue, which supports the organization of future events.

Conclusion

Knowledge and reflection on the experience of the 2010 Love Parade optimizes local emergency guidelines and planning for similar events. A coordinated cooperation of all involved is essential.     

Operative Behandlung von Verletzungen des thorakolumbalen übergangs Teil 2: Operation und r?ntgenologische Befunde Teil 2: Operation und r?ntgenologische Befunde

Die Autoren berichten über eine prospektive multizentrische Studie zur operativen Behandlung frischer Verletzungen des thorakolumbalen übergangs (Th10 bis L2). Die Studie soll die derzeitigen Behandlungsmethoden und ihre Ergebnisse an einem gro?en Kollektiv repr?sentativ analysieren und wird von der Arbeitsgemeinschaft “Wirbels?ule” der Deutschen Gesellschaft für Unfallchirurgie (DGU) erarbeitet. An 18 unfallchirurgischen Kliniken in Deutschland und ?sterreich wurden von September 1994 bis Dezember 1996 insgesamt 682 Patienten prospektiv erfasst. Die Nachuntersuchung der Patienten ist z. Z. noch nicht abgeschlossen. Im Teil 1 (Epidemiologie) wurden Studiendesign und epidemiologische Daten des Kollektivs dargestellt.     

Kommunikation im berufsgenossenschaftlichen Heilverfahren

Trauma und Berufskrankheit - Eine gelungene Kommunikation hat in der Arzt-Patienten-Beziehung nachweislich für beide Seiten Vorteile. Der Arzt muss umdenken, sich auf den informierten...     

Operative Behandlung von Verletzungen des thorakolumbalen Übergangs

The authors report on a prospective multicenter study with regard to the operative treatment of fractures and dislocations of the thoracolumbar spine. 18 traumatologic centers in Germany and Austria, forming the working group "spine" of the German Society of Trauma Surgery, are participating in this continuing study. Between September 1994 and December 1996 682 patients (64% male) with an average age of 39 1/2 (7-83) years were entered. The entry criteria included all patients with acute and operatively treated (within 3 weeks after trauma) fractures and dislocations of the thoracolumbar spine (Th 10-L 2). Part 1 of this publication outlines the protocol and epidemiologic data. The incidence of fractures and dislocations of the thoracolumbar spine and associated injuries were recorded according to a standardized protocol, as well as the different operative methods and complications, duration of hospital stay, rehabilitation and incapacity. The analysis of the clinical social and radiological course was a second focus. The most frequent mechanism of injury was a fall (50%) or traffic accident (22%). Most of the fractures occurred at the L 1 level (49%). All injuries were classified according to the ASIF (AO) classification. 65% sustained an A-type fracture (compression fracture). Associated injuries were observed in 35% and 6% were polytraumatized. Extremities and thorax were most frequently affected. Younger age and traffic accidents lead more often to C-type fracture (fracture dislocation) and polytrauma. An increased number of multisegmental or multilevel lesions were observed in polytraumatized patients. There were 16% with incomplete paraplegia (Frankel/ASIA B-D) and 5% with complete paraplegia (Frankel/ASIA A). The rate of patients with initial neurologic deficits significantly increased with the severity of spinal injury according to the Magerl classification. Until discharge a neurologic improvement (at least 1 Frankel/ASIA grade) was observed in 32% of the partially paralyzed (Frankel/ASIA B-D) and in 12% of the patients with complete paraplegia (Frankel/ASIA A). A neurologic deterioration occurred in 3 patients (0.4%). As a base for further follow-up and late results the individual starting point was determined by collecting relevant data of the patients' history: 277 (40.6%) patients suffered from simultaneous diseases, one half was spine related. At the time of injury 559 (82.0%) patients were employed; 429 (62.9%) doing manual work. 369 (54.1%) patients stated sportive activities before the injury and 561 (82.3%) designated their "back function" as normal. For the time before injury the patients scored an average of 93.4 points in the Hannover Spine Score (0-100 points concerning complaints and function of the back/spine).