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D Nast-Kolb

Publications and source records attributed to D Nast-Kolb.

At least 91 records · Page 5Linked to original sources
PubMed1997

[Acetabular and pelvic fractures in multiple trauma].

We see pelvic fractures in about 50% of all multiple trauma patients. In many cases, these pelvic fractures are complicated by complex pelvic traumata, i.e., a pelvic fracture with pelvic vessel damage, neurological, visceral or soft-tissue damage, and therefore have the character of life-threatening lesions. The incidence of complex pelvic trauma is extremely high in cases of vertical and rotation instability. Most problems come from massive bleeding as a result of presacral venous plexus laceration. This venous bleeding usually tampons its self after stabilization, e.g., with an external fixator. In about half of the cases an immediate laparotomy is performed because of remaining circulatory instability, lesions of the urinary tract, or open fractures. In these cases, stabilization of the pelvis is frequently achieved by ORIF, e.g., plating of the symphysis pubis or the SI joint. Internal stabilization of the pelvis facilitates the following treatment in the ICU, especially when prone-supine positioning is mandatory due to pulmonary indications. For this reason we avoid traction techniques in displaced acetabular fractures, and we achieve stability with a joint-bridging external fixator. Treatment of complex pelvic fracture must be integrated in the overall concept of treatment. Differentiated and situation-adapted action is necessary, depending on the particular situation, as well as the personnel and technical equipment.

Acetabulum↗
PubMed1997

[Treatment of Pipkin fractures].

Because of the controversy that exists about therapy for the Pipkin fracture, the treatment and results of 117 fractures of the femoral head were reviewed and re-evaluated at least 1 year after the trauma had taken place. The cases were taken from eight publications in the literature from 1983 to 1995. The lesions in this collection comprised 35% (n = 41) type I, 40% (n = 47) type II, 10% (n = 12) type III and 15% (n = 17) type IV fractures classified after the Pipkin system. Seventy-four percent of patients (n = 87) were operated on; only type I lesions were treated conservatively in 42%, thus more often than average. There were 57 complications with equally frequent head necroses (14.5%) and severe coxarthritis. Coxarthritis was doubled after conservative treatment versus operation (23% vs. 13%). There was no difference in respect to head necrosis. Postoperatively, 18 (14%) periarticular ossifications were registered. Forty-one (75%) of 55 Pipkin I and II fractures had an at least "good" outcome; the portion of conservative treatment was higher than operative treatment (88% vs 69%). Still these results have to be seen with respect to the use of treating simple lesions primarily conservatively with the minimum of 6 weeks of traction therapy, thus counting the latter patients in this group. According to the literature, we think that if there are no vital contraindications, all Pipkin fractures should be treated operatively (early emergency operation) by reattaching bigger fragments and extracting smaller fragments in Pipkin I and II fractures, trying to save the heads in young, active patients with Pipkin III fractures in contrast to primary endoprosthesis in elderly patients with coxarthrosis with Pipkin IV fractures (unstable and displaced fractures of the acetabulum).

Femur Head↗
PubMed1997

[Shock room diagnosis in polytrauma. Value of thoracic CT].

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest X-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information obtained influences subsequent decisions on therapy in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiply injured patients with chest trauma, 9 patients with isolated chest trauma) who had an average ISS of 30 and an average AIS thorax of 3, initial CXR and TCT were compared after the first assessment in our emergency department (a level I trauma center). Mortality in this group was 10% (n = 10). RESULTS: In 67 patients (65%) TCT revealed major complications of chest trauma that had been missed on CXR: lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax ((n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1); in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT; and in 14 patients CXR and TCT showed identical pathologic results. In 11 patients neither CXR nor TCT revealed pathologic findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (P < 0.001), pneumothorax (P < 0.005) and hemothorax (P < 0.05). In 42 patients (41%) the additional TCT findings did affect, the therapy selected: chest tube placement or chest tube correction in mostly anteriorly located pneumothoraces or large hemothoraces (n = 31), influence on ventilation mode and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions and pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work-up of multiple injured patients with suspected chest trauma, because early and accurate diagnosis of all thoracic injuries along with acceptance of the implications for therapy may reduce complications and improve the outcome in polytraumatized patients with blunt chest trauma.

Adolescent↗
PubMed1997

[Quality management in early clinical multiple trauma care. Documentation of treatment and evaluation of critical care quality].

Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm. The quality of present data recording was analysed, and criteria for judgement of quality of care were assessed. The algorithm was divided into 117 possible steps (one step consisting of a single decision criterion, the decision and the corresponding procedure). Per patient, only 61% +/- 12% of these steps were sufficiently documented to allow judgement. Using several criteria for assessment, the following baseline data could be observed (times shown refer to admission to the trauma room): (1) trauma room time of 129 +/- 55 min; (2) completion of basic radiological and sonographic diagnostics in 91% of patients; (3) first blood collection after 17 +/- 11 min; (4) cranial computerised tomography after 55 +/- 20 min; (5) missed injuries during the trauma room period in 32% of patients; (6) intubation after 20 +/- 19 min; (7) insertion of a chest tube after 30 +/- 17 min; (8) first blood transfusion in shock after 32 +/- 17 min; (9) transfused blood within the first hour of 4.2 +/- 2.8 units and within the second hour of 8.5 +/- 4.7 units; (10) emergency operations in shock after 98 +/- 55 min; (11) early operations after 156 +/- 69 min; (12) craniotomy after 124 +/- 37 min; (13) unplanned surgery within 24 hours after admission to the intensive care unit in 11% of patients. The study presented here supplies information on timing and other process data of the acute clinical care of seriously injured patients. In particular, the data represent indicators for the quality of emergency room management, which may be used as baseline to compose improvement measures of structure and process. The quality of data collection has to be improved for carrying out an exact analysis of the process.

Adolescent↗
PubMed1997

[Quality management in early clinical polytrauma management. II. Optimizing therapy by treatment guidelines].

To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3% vs. 12%. The lethality rates of each collective were assessed after subdivision in three groups (I-III) with middle (ISS: 18-24), high (ISS: 25-49) and extreme (ISS: 50-75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0% vs. 20% (P < 0.05); group II, 8% vs. 24% (P < 0.05); and group III, 40% vs. 71%, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.

Adult↗
PubMed1997

[Algorithms in trauma management].

A well-controlled, meticulous process has a far higher probability of resulting in a high quality of medical care than improvization and unstructured creativity. Algorithms display decision-making treatment processes and problem-solving strategies by giving clearly defined and formalized guidelines. The flow chart for decision-making follows the yes/no dichotomy of binary logic. The systematic ordering of decision points and consequent actions is guided by medical priority and thus regulates the time-frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. Clinical algorithms represent scientifically recognized treatment rules, indicate a solution for solving problems and help users to organize ideas and recognize connections. They delineate a consistent and valid guideline, while allowing deviations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured means of problem solving for the less experienced user. Algorithms are useful instruments in the teaching of medical decision-making.

Algorithms↗
PubMed1997

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND: Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS: Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS: The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS: These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Adolescent↗
PubMed1997

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

Adolescent↗
PubMed1997

[Intramedullary nailing in polytrauma. Pro and contra early management].

The progress after multiple trauma is influenced by the extent of the initial injury and the resulting inflammatory response as well as by the severity of the thoracic trauma. Primary stabilisation of the femoral fracture is compulsory to ensure adequate intensive and respiratory care, e.g. changing between a supine and prone position. Intramedullary nailing in multiple trauma patients is still controversial. Because of retrospective studies concerning the time of operation in patients with multiple trauma of minor severity, primary intramedullary nailing is the method of choice in the Anglo-American section. In German-speaking areas, however, differentiated management has been established because of knowledge of the shock pathogenesis. Intramedullary nailing leads to an additive trauma in the sense of traumatic haemorrhagic shock. This is due to local pulmonary embolisation and systemic inflammatory reactions. Therefore, in severe injuries (ISS > 29 points) and/or severe thoracic trauma (AIS > 3), primary stabilisation by external fixation should be preferred, whereas intramedullary nailing, especially the less risk unreamed nailing, is to be recommended in patients with minor injuries. Definite fracture healing should be achieved by a change to intramedullary nailing in a secondary operation.

Cause of Death↗
PubMed1997

[Can diagnosis and subsequent trauma management of the multiple trauma patient with blunt thoracic trauma be improved by early computerized tomography of the thorax?].

OBJECTIVE: The aim of this prospective study was to evaluate, whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work up of blunt thoracic trauma and whether these additional informations influence subsequent therapeutical decisions in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiple injured patients with chest trauma, 9 patients with isolated chest trauma) with an average ISS of 30 and an average AIS thorax of 3 initial CXR and TCT were compared after first assessment in our emergency department of a level I trauma center. RESULTS: In 67 patients (65%) TCT detected major complications of chest trauma, that have been missed on CXR [lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)], in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT and in 14 patients CXR and TCT showed the same pathological results. 11 patients had both CXR and TCT without pathological findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005) and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement or chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work up of multiple injured patients with suspected chest trauma, because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

Adolescent↗
PubMed1997

[Evaluation and quality management in multiple trauma care].

In total quality management of polytraumatised patients, it is necessary to use analysis of structure, process and outcome quality to search for problem areas and improvement possibilities. The structure includes the attributes of material and human resources. The process denotes the real treatment course with the demand for treatment guidelines (algorithm) and an exact documentation of treatment. To prove the outcome quality, an internal and external judgement is possible. Our own results show that quality assessment, concerning the process as well as the internal and external quality outcome, brings a significant improvement to the care of polytrauma patients.

Algorithms↗
PubMed1997

[A time and priority-oriented algorithm].

Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. They delineate a consistent and valid guideline but require aberrations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured way of problem-solving to the less experienced user. Algorithms are useful instruments in teaching medical decision-making.

Algorithms↗
PubMed1997

[Shock room management in severe craniocerebral trauma].

Early clinical management of severe head injury should take place in an emergency resuscitation room and be conducted according to the guidelines of the treatment of severely injured patients with attention given to time. The first phase (with a maximum duration of 30 min) comprises physical examination, stabilisation of vital functions and basic technical diagnostics. With pulmonary and circulatory functions stabilized, the second phase begins with a craniol computed tomography examination followed by adequate therapeutic measures, including, if necessary, the CT-controlled implantation of an intracranial pressure catheter.

Brain Edema↗
PubMed1997

[The trauma register of the 'Polytrauma' Committee of the German Society of Trauma Surgery as the basis for quality management in the management of severely injured patients].

The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in respect to the treatment criteria (i.e., duration of basic diagnostics in severe trauma) and quality of outcome (TRISS method and Z statistic) were revealed for some clinics. The feedback of their data offers the associated clinics the possibility of identification of treatment phases that are worth being optimized.

Germany↗
PubMed1996

[The injury pattern in polytrauma. Value of information regarding accident process in clinical acute management].

To investigate the correlation between the mechanism of an accident and the resulting injury pattern we reviewed the data of 195 prospectively documented multiply traumatized patients. Information on the accident was based on descriptions given by eye witnesses, police and the emergency medical staff. Only moderate to severe lesions (AIS > or = 3; Abbreviated Injury Scale Version 1990) of each body region were analyzed. The mean injury severity (ISS) for all these patients was 39.5 (18-75); the lethality was 34%. Different types of accidents led to various injury patterns. We found a high incidence of lesions of the head in frontal (F) motor vehicle crashes (MVC) nonbelted (76%), of the chest in lateral (L) MVCs (80%), of the abdomen in F MVCs belted and in LMVCs (60%), of the pelvis after suicidal fall (SF; 69%) and of the lower extremities in motorcycle accidents (90%), SFs (69%) and collisions with a train (67%). Severe lesions of the spine were frequently seen after accidental falls (41%), SFs (30%) and F MVCs belted (25%). There was a very substantial difference in the injury pattern after suicidal jump (26% head, 69% pelvis, 65% lower extremity lesions). and accidental fall (54% head, 19% pelvis, 23% lower extremity lesions). As a result of the correlation with specific injury patterns, the preceding mechanism of accident should be exactly documented and considered by the physician during the early phase of resuscitation.

Abbreviated Injury Scale↗
PubMed1996

Posttraumatic inflammatory response, secondary operations, and late multiple organ failure.

The objective of this study was to determine the role of surgical procedures as secondary inflammatory insults in the development of late multiple organ dysfunction syndrome in patients with multiple trauma and to evaluate both specific and nonspecific indicators of the inflammatory response in their ability to indicate the risk of severely injured patients to develop organ failure after secondary operations. In a prospective study of 106 severely injured patients (ISS 40.6) who underwent secondary operations (> 3 days after trauma), we compared the level of preoperative inflammation with the sequelae of surgical trauma. The interventions included facial reconstructions; osteosynthesis of the pelvic girdle, long bones, and spine; and others. Group 1 consisted of 40 patients (38%) who developed respiratory, renal, or hepatic failure, or combinations thereof, within 2 days after the operation or whose preexisting organ dysfunction worsened by more than 20% from baseline. The remaining 66 patients (62%) with an uneventful recovery formed group 2. The preoperative levels of neutrophil elastase (92.2 vs. 61.3 ng/dL), C-reactive protein (12.4 vs. 7.6 mg/dL), and platelet count (118,000 vs. 236,000/microL) were significantly more abnormal in the patients of group 1. PO2/FiO2 ratio was also somewhat lower in group 1 patients (305.5 vs. 351), whereas other parameters (e.g., blood pressure, heart rate, bilirubin, creatinine, urinary output, lactate, pH, and coagulation) did not allow preoperative differentiation between groups 1 and 2. An increased state of inflammation (neutrophil elastase > 85 ng/mL, C-reactive protein > 11 mg/dL, platelet count < 180,000/microL) predicted postoperative organ failure with an accuracy of 79% (sensitivity, 73%; specificity, 83%). We conclude that secondary operations may act as a second insult and may precipitate late multiple organ dysfunction syndrome if they are performed in patients with multiple trauma while they still have an increased level of posttraumatic inflammation. However, future investigations have to show whether postponing surgery until inflammation has subsided or the use of less invasive surgical techniques will decrease the rate of postoperative organ failure in the trauma patient.

Adult↗