Injuries of the intraabdominal organs at patients with polytrauma.

The authors analyse group of 77 patients with several injuries of the intraabdominal organs by polytrauma and intraabdominal continuing bleeding. The injuries were classified in compliance with the classification of the American Association for the Surgery of Trauma (AAST), 1994. At hemodynamically stable patients, the authors accept selective non-operative forms of treatment, however are aware of the risk of delaying the therapy of severe polytrauma. (Tab. 4, Fig. 2, Ref. 3.).

Stabilisation of thoracic wall in patients with chest injury.

The authors analyse a group of 38 polytraumatised patients with unstable thoracic injury who were subdued to internal surgical stabilisation of the thoracic wall during the period from 1st October 1994 to 30th September 2001. The average period of controlled pulmonary ventilation (CPV) was 3 days and the average period of hospitalisation at the Anaesthesiology and Intensive Care Department (AICD) was 10 days. In indicated cases, the authors recommend an active surgical approach in the treatment of patients with unstable thoracic injuries. (Tab. 2, Fig. 2, Ref. 3.).

[The current approach to liver injuries]. / Súcasný prístup k poraneniam pecene.

PURPOSE OF THE STUDY: The authors analyze their own three-year material within the treatment (both surgical and conservative) of the injury of liver. MATERIAL: During the given period 18 patients with the injury of liver were treated, of which 15 (83%) surgically and 3 (17%) conservatively. The group included 13 men (72%) and 5 women (28%), the average age at the time of injury was 30 years (range, 19-44 years). Ten patients (56%) suffered a blunt injury and 8 patients (44%) a penetrating injury, of which in 5 patients it was the case of a stab wound and in 3 patients a gunshot wound. METHODS: Indicated to operation were patients with a continuous intraabdominal bleeding, multiple organ injury of the abdominal cavity, simultaneous injury of diaphragm and gunshot wounds in the abdominal cavity. The method of treatment of the liver was determined by the extent of the injury. The authors accept the selective non-surgical treatment of hemodynamically stabilized patients which was developed on the basis of modern imaging methods. The condition of patients is also limited by the extent and severity of associated injuries. Hepatic injuries were classified according to American Association for the Surgery of Trauma, 1994. RESULTS: The average amount of hemoperitoneum in the patients operated on amounted to 1 550 ml. (200-4000) of blood, the average number of transfusion units 9 (4-20), the average duration of hospitalization at the intensive care unit was 7 (1-44) days and at the surgical department 10 (1-24) days. The average amount of hemoperitoneum according to Federle classification in the nonoperated on patients was 250 ml (200-375), the average number of transfusion units was 1.2 (1-2) of erythrocyte mass, the average duration of the stay in the intensive care unit of the surgical department was 2.3 (2-3) and at the surgical department 6.9 (6-8) days. Complications were recorded in 5 (28%) patients. During resuscitation 6 patients (33%) died due to hemorrhagic shock and in 2 (11%) patients we introduced during the resuscitation intracaval shunt. DISCUSSION: Non-surgical treatment has become a standard method of the treatment of a blunt hepatic, injury in the adult population and it is used in the extent of 50-82%. Failure of conservative treatment at present leads to a surgical intervention. Surgery is indicated in patients which continuously require transfusions, whose vital indicators have deteriorated and where there are evident growing signs of peritoneal irritation. CONCLUSION: Non-surgical treatment of blunt hepatic injuries should be initial in all patients with a secured hemodynamic stability. As it is impossible to find out in which patients non-surgical treatment will fail, the initial period of observation at the intensive care unit is a guarantee of a selective approach. If all its principles are observed the percentage of success of this treatment should exceed 90%.

[Resuscitation operations in patients with multiple injuries]. / Resuscitacné operácie u polytraumatizovaných pacientov.

The authors analyze a group of 15 patients with polytrauma during a 4-year period. The patients had the clinical signs of severe bleeding. Despite the complex resuscitation care, the patients died due to consequences of haemorrhagic shock already during the operation or very soon after operation. All patients were after initial resuscitation and diagnostic procedures (apparatus breathing, aggressive volumotherapy, proved continuous bleeding) performed for the use of further resuscitation actions, namely surgical control and stoppage of bleeding, surgical indications. This pathophysiological consideration is reflected also in the title of this study. The study further discusses the modern injury conception of resuscitation at a operating theatre which in frame of surgical intervention attempts to achieve homeostasis. At the same time, the surgical approach frequently must prefer the methods which enable the physiological stability on the behalf of incomplete solution of post-traumatic anatomic integrity. The definite solution can be possibly performed by subsequent operation. (Ref. 5.)

[Significance of monitoring of intracranial pressure in craniocerebral injuries.]. / Význam monitorovania intrakraniálneho tlaku pri kraniocerebrálnych poraneniach.

The authors extend the analysis of the previously published group of 26 patients with a craniocerebral injury during a 20-month period of monitoring of intracranial pressure by means of epidural approach by new techniques. Since 1996 they have implanted a technically upgraded intracranial pressure censor intraparenchymatosely and since 1998 intraventricularly in total in 27 patients with craniocerebral injury during 36-month period. The significance of continuous monitoring of intracranial pressure in indicated cases consists in the prevention and treatment of intracranial hypertension (medicaments, ventilation regimen, nursing care) as in craniocerebral injuries ther does not develop a direct relationship between the disorder of conscience and intracranial pressure. Key words: craniocerebral injuries, monitoring of intracranial pressure, intracranial hypertension.

[Injuries of diaphragm in our group of patients.]. / Urazy bránice v nasom klinickom materiáli.

In thoracic and abdomen surgeries the injury of diaphragm is often neglected. Clinical symptoms vary and in patients with polytrauma they are usually disguised. The authors analyze a group of 9 patients with polytrauma with the injury of diaphragm during a five-year period (from 1 September 1993 to 31 August 1998) specifying diagnostic possibilities and stressing the necessity to revise the diaphragm in laparotomy or thoracothomy for associated injuries. The prognosis of the injury is given by associated injuries. Key words: injury of diaphragm, polytraumatic patient.

[Topical issue of the injury of liver.]. / Aktuálna problematika poranenia pecene.

The authors analyse their own 10-year clinical material (1 August 1987-31 July 1997). In the course of this period they operated on 40 patients for the injury of liver. The indications were persisting intra-abdominal bleeding, multiple injuries of organs in the abdominal cavity, simultaneous injuries of diaphragm and gunshot wounds of abdomen. Injuries were classsified according to AAST, the range of organ injury - liver. The treatment of liver was determined by the extent of the injury. In their surgical strategy the authors prefer suture of hepar by collagenous stripes (Parenchymaset, Braun) with sufficient drainage, but they also used resection or packing in dilaceration injuries. Patients with injuries of hepatic veins and retrohepatic inferior vena cava died in the course of resuscitation surgery despite the introduction of en-docaval shunt. The authors accept selective non-surgical treatment of hemodynamically stabilised patients which has been developed thanks to modern visualisation methods. However, such treatment implies a risk of delayed management of significant associated injuries. The fate of patienst is also limited by the extent and seriousness of associated injuries. Key words: liver injury, surgical and non-surgical treatment.

[Early treatment of unstable chest in patients with multiple injuries.]. / Vcasné osetrenie nestabilného hrudníka u polytraumatizovaných pacientov.

The authors analyze a group of 11 patients with unstable chest injuries who were subjected in 1994-1996 to internal surgical stabilization of the chest wall. They compare them with a group of 11 consecutive patients from the previous period who were treated by artificial pulmonary ventilation. The basic indicator for evaluation of both groups was the necessary length of assisted ventilation which had an impact on all important parameters, complications and mortality of patients with this injury. Patients in the group with surgical stabilization of the chest wall needed on average three days of assisted ventilation and their mean time spent in the resuscitation department was 10 days. On the other hand, patients in the ventilated group needed on average 15 days of assisted ventilation and spent 25 days in the resuscitation department. The authors recommend in indicated cases an active surgical approach to the treatment of patients with unstable chest injuries. Key words: polytrauma, unstable chest injury, stabilization of the chest wall.

[Therapy of tracheal stenoses]. / Liecebné moznosti tracheálnej stenózy.

BACKGROUND: Tracheal stenosis is a serious disease of the upper airways. With advances in resuscitation its incidence is steadily increasing. Despite modern therapeutic procedures and the use of perfect materials tracheal stenosis is still a serious therapeutic problem. METHODS AND RESULTS: The authors present a group of 48 patients with tracheal stenosis treated during the period between January 1990 and September 1995. Thirty-eight patient with postintubation stenosis were subjected to surgery. 4 with direct tracheal injury, 5 with a tracheoesophageal fistula and one with a malignant stenosis of the trachea. For treatment of tracheal stenosis a wide range of therapeutic procedures was used: from laser destruction to long-term stenting on a T cannula and plastic reconstruction of tracheal defects to extensive segmental resections of the trachea. In the group of patients with segmental resection of the trachea (21 patients) in 17 good results were achieved (81%), in three satisfactory results (14%) and one patient died during the postoperative period. In the group with combined treatment (27 patients) in 13 good results were recorded (48%), in three satisfactory results (11%), in nine patients treatment still proceeds (33%) their prognosis in uncertain. During the postoperative period two patients died. CONCLUSIONS: From the results of the work the authors conclude that segmental resection of the trachea holds a priority position in the treatment of tracheal stenoses. It gives the best immediate and late therapeutic results. It is important to emphasize prevention of tracheal stenoses during prolonged controlled ventilation. Because the most difficult tracheal reconstructions are those after unsuccessful primary reconstructions, it is essential to concentrate serious tracheal lesions in departments which have adequate staff and technical equipment and ample experience.

[Monitoring of the intracranial pressure in craniocerebral injuries.]. / Monitorovanie intrakraniálneho tlaku pri kraniocerebrálnych poraneniach.

The authors analyzed a group of 26 patients with serious craniocerebral injuries during a 20-month period, where the total mortality was 26 %. The majority of injuries was contracted during traffic accidents and the most frequent CT finding on admission was traumatic subarachnoidal haemorrhage and contused and haemorrhagic foci in the brain. As during craniocerebral injuries no direct relationship develops between impairment of consciousness and intracranial pressure the authors recommend continuous assessment of the intracranial pressure. It is important for prevention and treatment (medicamentous, ventilation regimen and nursing care) of intracranial hypertension. Key words: craniocerebral injury, monitoring of intracranial pressure, intracranial hypertension.

[Thoracoabdominal operations in patients with multiple injuries.]. / Torakoabdominálne výkony u polytraumatizovaných pacientov.

The authors analyze during a two-year period a group of 58 patients with multiple injuries, including a thoracoabdominal injury, with a total mortality of 29 %. The dominating injury was damage of the chest and the most frequent surgical procedure negative pressure drainage of the pleural cavity, as described by Büllau. 82% of the surgical procedures were performed during the acute stage of treatment of the multiply injured patient (unstable patient) within 8 hours after admission to hospital. If peroperative coagulopathy develops, the authors recommend intraabdominal packing, closure of the abdominal cavity and after the patient's stabilization (haemodynamics, ventilation, milieu intérieur) definitive surgical treatment. Key words: polytrauma, peroperative coagulopathy, intraabdominal packing, definitive surgical treatment.