[The preclinical care of polytraumatized patients]. / Die präklinische Versorgung des polytraumatisierten Patienten.

In industrially developed countries, trauma is the major mortality factor for people younger than 40 years. The preclinical management of polytraumatized patients influences the prognosis of mortality and morbidity. In this period, a number of decisions have to be made under unfavourable conditions and with limited time. This situation represents a great challenge for the whole rescue team. Diagnostic overview, protection of the vital functions under the special situation of shock, immobilization of the spine and the treatment of the isolated injuries are part of the preclinical management efforts. Rescue of the polytraumatized patient, organization and announcement of transfer and the protection of the rescue team have to be taken into account.

[Metoclopramide and dexamethasone in prevention of postoperative nausea and vomiting after inhalational anaesthesia]. / Metoclopramid und Dexamethason zur Prophylaxe von postoperativer Ubelkeit und Erbrechen nach balancierter Anästhesie.

OBJECTIVE: Because of its complex profile of action (binding to dopamine, serotonin and histamine receptors), low rate of adverse effects and low cost as a medicinal preparation, metoclopramide is an interesting substance for the prophylaxis of post-operative nausea and vomiting (PONV). As a single substance its antiemetic effects are slight at the usual dose, so the aim was to test the efficacy of a combination of metoclopramide and dexamethasone for the prevention of PONV on a group of patients with the same operative trauma. METHOD: All patients (n = 204) were recruited prospectively (January-October 2002) and were to undergo a lumbar disc operation. The anaesthetic was administered according to a standard procedure as a balanced anaesthetic with fentanyl and isoflurane in oxygen/air. 60 min before the end of the operation, all patients were given 10 mg of metoclopramide and 8 mg of dexamethasone intravenously. The Würzburg-Oulu-Score served as an instrument for comparison, because no placebo group has been included. 24 hours after the operation, all patients were asked to report on nausea and vomiting, stating the time and the degree of discomfort (quantification by means of an analogue numerical scale from 0-10). The influence of age, height, weight, duration of the anaesthetic, operating position and increased dexamethasone dose was analyzed in addition to the risk factors according to the score. The cost analysis was based on the purchase prices of the hospital dispensary. RESULTS: The expected PONV incidence was 35.8%; 10% nausea (average intensity 4.3) and 3% emesis (4.8) was reported for the 24-hour period. The rescue medication (dimenhydrinate) was requested 8 times. Nausea was mainly during the early part of the period (0-6 hours). Of 42 patients with a history of PONV, 71% had no symptoms. The Odds Ratios for female sex (2.9), non-smoker status (2.0) and post-operative opioid administration (1.9) correspond to the data given in the literature; it was not possible to determine the significance of a history of PONV as an independent risk factor. None of the other factors investigated had a significant influence on PONV. For the chosen combination of antiemetic drugs the number-needed-to-treat is 3.9 (95% CI: 3.3-4.7). The direct costs of the PONV prophylaxis are 0.65 euro per patient. CONCLUSIONS: The metoclopramide/dexamethasone combination proved to be effective and inexpensive, on the basis of these findings it is used prophylactically at our hospital if only one PONV risk factor exists.

Prognostic significance of SSEP, BAEP and serum S-100B monitoring after aneurysm surgery.

OBJECTIVE: Changes in evoked potentials (EPs) and increased levels of S-100B protein were used to identify cerebral ischemia or glial damage and to predict neurological outcome in aneurysm patients. MATERIAL AND METHODS: Somatosensory evoked potentials and Brainstem auditory-evoked potentials, and serum S-100B protein were simultaneously investigated pre- and postoperatively over a period of 10 days in 43 patients with 47 aneurysms (six in the posterior fossa). RESULTS: The EP scores showed a strong correlation with the clinical outcome. Sensitivity was 73%, and specificity 81%. Pathological S-100B levels >0.5 mg/l were equal in predictive values (correct positive eight, false positive six, correct negative 26, false negative three). Initially increased S-100B levels, long-lasting S-100B elevation, and secondary increasing S-100B values correlated with an unfavorable outcome. High peak S-100B values correlated with bad EP scores at discharge. EP deterioration was the first indicator anticipating S-100B elevation and clinical deterioration in five patients. There was a good correlation between pathological S-100B values or EP findings and infarction on CT scan. CONCLUSIONS: Both EPs and S-100B protein showed a comparable high predictive value for outcome. S-100B reflects the extent of primary brain damage after subarachnoid hemorrhage and time course of ongoing secondary brain damage. Evoked potentials assess the functional integrity and tended to react earlier than S-100B protein before definitive structural damage occurred.

Coagulopathy and outcome in patients with chronic subdural haematoma.

OBJECTIVE: The coincidence of coagulatopathy and chronic subdural haematoma (CSH) requires correction of coagulation to facilitate surgery. We investigated the correlation between coagulopathy and outcome in CSH patients. MATERIAL AND METHODS: We analysed past medical history, surgical treatment and coagulation parameters of 114 patients. RESULTS: Coagulation disorders were found in 42%. Preoperative treatment with prothrombin complex concentrate was necessary in 14%. A significant difference (P < 0.05) of the preoperative level of platelets was found between recurrent CSH and non-recurrent group. Totally, we had to perform re-operations in 17.5%. Eighty-one patients presented with Glasgow coma scale (GCS) > or = 13. After surgery GCS was > or = 13 in n = 92. There was an improvement of GCS in 46 cases, 61 patients maintained GCS score levels. Outcome was significantly worse in the alcoholic group (P < 0.001), and in the recurrent group (P < 0.05). In patients with substitution of coagulation factors, outcome was worse in the group with post-operative substitution only (P < 0.05). CONCLUSION: In CSH, the coagulation parameters and a subtle correction of coagulation are of special interest, regarding the worse outcome in patients with recurrent CSH and in those requiring post-operative substitution.

Technique of microendoscopy in medial lumbar disc herniation.

Various percutaneous techniques to approach the lumbar disc were studied in the past. Chemonucleolysis, laser vaporization, lateral endoscopic foraminal approaches and different techniques of percutaneous nucleotomy remained disappointing due to insufficient root visualization, insufficient decompression or insufficient disc removal. The microendoscopic discectomy is performed via a median approach that allows thorough root exploration, direct evaluation of the compression and determination of contained or non-contained disc material. This is achieved by applying open surgical tools through a tubular retractor under endoscopic visualization. The endoscope is inserted via a sequential set of dilators passed over the initial guide wire. The technique allows a smaller incision and less tissue trauma with comparable visualization of the nerve structures than does standard open surgery.

Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study.

This study investigated electromyographic (EMG) activity as a marker of nerve root irritation during two different surgical procedures for lumbar disc herniation. Mechanically elicited EMG activity was recorded during the dynamic stages of surgery in muscle groups innervated by lumbar nerve roots. Confirmation of surgical activity was correlated with the activity of the electromyogram. Fifteen patients with lumbar disc herniations were treated via an endoscopic medial approach, and 15 patients via the open microscopic surgical technique. Results indicated that the endoscopic technique was superior to the open surgical technique and produced less irritation of the nerve root. Significantly less mechanically elicited activity was recorded during both the approach and the root mobilization. The study showed that microendoscopic discectomy allows a smaller incision and less tissue trauma with comparable visualization of the nerve structures than does open surgery.

Intradiploic arachnoid cyst with extensive deformation of craniofacial osseous structures: case report.

OBJECTIVE AND IMPORTANCE: A unique case of a large intradiploic arachnoid cyst involving craniofacial osseous structures is reported. CLINICAL PRESENTATION: The patient presented with a hard mass in the right frontal region, proptosis, and inferior globe displacement. Computed tomography revealed an intraosseous cyst of cerebrospinal fluid intensity with extension from the anterior cranial fossa to the infratemporal fossa. INTERVENTION: After resection of the cyst wall and closure of two small round dural defects, the involved craniofacial region was reconstructed. CONCLUSION: The medical history of the patient and the intraoperative observations support the contention that the cyst in the reported case was congenital in origin. The features concerned with diagnosis and pathogenesis of this rare entity are discussed.

Correlation of computed tomography findings and serum brain damage markers following severe head injury.

The objective of our study was to investigate the association between the initial levels of serum S-100B protein and neuron specific enolase and the severity of radiologically visible brain damage and outcome after severe head injury. Admission computed tomography (CT) scans of forty-four patients with severe head injury were analysed. Initial levels of S-100B protein and neuron specific enolase were compared between the different outcome groups at 6 month, the different categories of the Marshall classification, the presence of traumatic subarachnoid haemorrhage, the type of haematoma and the volume of contusion. Serum S-100B was significantly higher in patients with unfavourable outcome (1.1 micrograms/l versus 0.3 microgram/l, p < 0.005, Mann-Whitney U test). In diffuse injury, unfavourable outcome significantly increased with higher Marshall grades (p < 0.05). There was a significant correlation between the four grades of diffuse injury and initial serum S-100B protein (r = 0.48, p < 0.001). Patients with focal mass lesions and a favourable outcome after 6 month had significantly lower S-100B values than those who had an unfavourable outcome (0.51 microgram/l versus 1.3 micrograms/l, p < 0.05). A significant correlation was demonstrated between the volume of contusion visible on CT scans and serum S-100B (r = 0.58, p < 0.001). In our study, initial serum S-100B protein was a powerful predictor of outcome even within the same category of radiologically visible brain damage. Serum S-100B protein may provide independent information about the severity of primary brain damage after head injury.