Abstract: Secondary abdominal compartment syndrome (ACS) is a severe complication in patients admitted to burn intensive care units (BICUs). Unlike patients with thermal burns, patients with toxic epidermal necrolysis (TEN) present with a different pathophysiology and usually require less fluid.
Abstract: The objective of this study was to analyze the prehospital use of a Glidescope video laryngoscope (GSVL) due to anticipated and unexpected difficult airway in a helicopter emergency medical service setting in which emergency physicians (EP) are experienced anesthetists. Retrospective observational study and survey of the experiences of EP were conducted for more than a 3-year period (July 2007-August 2010). In 1675 missions, 152 tracheal intubations (TI) were performed. GSVL was used in 23 cases (15%). A total of 17 patients presented with multiple traumas, including nine with cervical spine immobilization, three with burns, and three with nontraumatic diagnoses. Eight patients experienced previously failed TI with conventional laryngoscopy (five by nonhelicopter emergency medical service EP). In two patients, the EP required two attempts with GSVL to obtain a successful TI. Since the introduction of the GSVL, no other backup airway device was necessary. GSVL may be a valuable support instrument in the prehospital management of difficult airways in emergency patients.
Abstract: We report the case of a perioperative cardiac arrest (ventricular fibrillation) of a patient undergoing elective orthopedic surgery due to moderate hypokalemia (serum potassium 2.8 mmol/l), whereas preoperative levels were normal. He was successfully resuscitated without neurological deficits and underwent postoperative intensive care monitoring. In times of increasing populations of elderly people presenting with considerable co-morbidity, clinicians should be aware of possible rapid changes of electrolyte levels resulting in perioperative cardiac arrhythmia.
Abstract: Bleeding and clotting disturbances are not uncommon in trauma patients and require an early and consequent therapy. Under the prevalent pathophysiological circumstances of hypothermia, acidosis and clotting disturbances, desmopressin seems to be a possible option to control diffuse bleeding. We report about 2 trauma patients with diffuse bleeding and in whom desmopressin was used successfully to control bleeding from the point of view of the authors. We discuss the advantages and disadvantages of desmopressin in the 2 patients.
Abstract: The authors report the case of a 29-year-old pregnant woman (2g1p) in the 16th week of gestation presenting with extensive toxic epidermal necrolysis (TEN). The cutaneous symptoms began at hands, feet, and in the mouth and developed during the course of 10 days to cover 75% of her TBSA, whereas total epidermolysis was present on more than 40% of her TBSA. Because of progressive swelling and bleeding of the oral mucosa, tracheal intubation was necessary to secure the airway of the patient. Critical care management required sedation, tracheotomy and artificial ventilation (14 days), prolonged fluid resuscitation, daily wound care, topical antiseptic and systemic antibiotic medication, hemostatic therapy and blood transfusion, hypercaloric nutrition, and frequent obstetric ultrasound evaluations. Reepithelialization began simultaneously with progressive epidermolysis and was completed after 35 days of conservative treatment. Because the patient experienced a swollen vulva and a stenotic birth channel, typical sequelae of TEN, a primary cesarean section was required after 40 weeks of gestation. The male infant showed neither signs of skin detachment nor sequelae caused by the prolonged therapy for the mother. A multidisciplinary approach and appropriate medical infrastructure are required to solve the challenge of TEN in pregnancy. In addition, the particular role of gestation in the pathophysiology of TEN needs to be explored further.
Abstract: The authors report a case of a 29-year-old male patient with severe burn injuries (54% TBSA) and inhalation injury. He developed a candidemia and a cutaneous zygomycotic superinfection with Rhizopus oryzae while he received burn intensive care. Despite aggressive surgery, sepsis persisted, and therapy was limited by uncontrollable coagulopathy and catecholamine refractory shock after 15 days. Autopsy revealed a thromboembolic occlusion of the basilar artery that resulted in liquefactive necrosis of the basal brain tissue and the brain stem. Because cerebral vessel occlusions after burn injuries are reported rarely, the current literature was reviewed, and possible pathophysiological aspects are discussed.
Abstract: INTRODUCTION: Although severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are rare, they are associated with considerable morbidity and mortality. METHODS: The current knowledge regarding background, differential diagnoses, critical care and implications for inter-hospital emergency medical service (EMS) transport of these patients is discussed. CONCLUSION: SCAR patients will substantially benefit from early interdisciplinary care and thorough consideration of complications during EMS transport and intensive care treatment.
Abstract: In Europe, long-distance repatriation flights are usually executed by fixed-wing aircraft. We report an international long-distance repatriation flight by the helicopter emergency medical service (HEMS), with a total flight time of almost 7 hours. The flight itself, the medical requirements, and aviation problems are discussed. The operation of the flight itself was almost uneventful thanks to careful preflight planning; however, it also proved challenging because of national regulations and airspace structures, which were somewhat different from those of Germany. The treatment of the patient during the flight was not affected by the extraordinarily long distance. We conclude that a combination of appropriate preflight planning, radio communication, and close cooperation with legal authorities is the key to accomplishing a successful execution of an international repatriation missions by the HEMS.
Abstract: We report a 20-year-old male who suffered smoke inhalation injury and burns covering 26% of his TBSA, including his face, dorsal chest, and both the arms. The Abbreviated Burn Severity Index was 5 (likelihood of survival 95%). He underwent burn surgery, requiring massive transfusion. Postoperatively, he appeared increasingly hyperthermic, showed respiratory exhaustion, and was neutropenic (lowest white blood cell count was 0.8 Gpt with a normal granulocyte count). He developed acute respiratory distress syndrome, renal failure, and severe inflammatory response syndrome. Aggressive ventilation patterns, intermittent prone positioning, and high-dose catecholamine therapy were performed. Hydrocortisone therapy and antibiotic prophylaxis did not improve his clinical status. He died after 12 days of septic multiple organ failure. Legal medicine autopsy identified aggressive Candida famata mycosis. The organism mainly affected the alimentary canal, and there were multiple pyemic abscesses in tissues of the heart, liver, spleen, kidneys, lungs, and meninges. Histology confirmed gastric ulcers as the source of the Candida infection. Despite the autopsy findings, all intravital specimens collected (blood, urine, and tracheal mucus) and all clinical Candida antigen tests were unsuspicious. Postoperative neutropenia may be a warning sign of severe infection even in survivable burns. Suppression of immune response and possible previous gastric Candida colonization may contribute to hazardous outcomes. However, delayed and unreliable methods to detect fungal infections remain a major problem in burn care. Occult aggressive fungal sepsis resulting in early multiple organ failure should be kept in mind.
Abstract: With great interest, I read the paper of David J. Dries about recent developments, infection control and outcomes research in the management of burn injuries. I have some comments about an important, however missing, topic in the paragraphs concerning infection control.
Abstract: ABSTRACT: BACKGROUND: Blood transfusion is a common therapy for multiple trauma patients, and is often performed soon after hospital admission. It is unclear whether the need for a blood transfusion in multiply injured patients presenting with a positive blood alcohol concentration (BAC) is associated with increased morbidity/mortality, since their risk behavior differs significantly from patients with a negative BAC. In this study, we evaluated the role of blood transfusion in the treatment of BAC-positive multiple trauma patients. PATIENTS: In a three-year period, 164 patients at a single trauma center presented with a positive BAC, and 145 met the inclusion criteria for further evaluation and regression analysis. We compared patients who were transfused (n = 76) with those who were not transfused (n = 69). RESULTS: In both groups, the most common causes of trauma were traffic accidents and falls. Most patients were admitted to the hospital from the scene of the accident (77.2%) and were male (89.0%). Transfused patients had a lower GCS (p </= .001) and her ISS (p </= .001), were more likely to have severe head injuries (p </= .001), tended to have higher BACs (p = .053), had lower hemoglobin levels and prothrombin times in the first 24 hours (p </= .001), had lower lactate levels, had higher rates of intubation (p </= .001) and ICU admission, and had longer ICU stays and artificial ventilation times (p </= .001). Mortality was significantly higher in transfused patients (n = 15 vs. n = 3, p </= .001). Non-survivors were more likely to have severe head injuries; be intubated and ventilated; be older; have higher ISS scores, lactate levels, and numbers of transfusions in the first 24 hours; and have lower GCS scores, hemoglobin measurements, and prothrombin levels. In a binary logistic regression model, only age (p = .009) and ISS (p = .004) independently predicted mortality. CONCLUSION: In our single-center study, the BAC of multiple trauma patients and the number of blood transfusions they received did not predict mortality in multiple trauma patients if used as independent predictors. Prospective studies with greater sample sizes should be performed to clarify the role of blood transfusions in the outcome of this sub-population.
Abstract: BACKGROUND: The lost guidewire in central venous catheterization is a commonly described complication. The percutaneous endovascular retrieval method is safe and has a very low complication rate. OBJECTIVES: Guidewires extending to the inferior cava vein are usually retrieved via the femoral vein. Under special circumstances, femoral venous access may be impossible and alternative vascular approaches are required. CASE REPORT: We report a case in which we used an alternative vascular approach, from the subclavian site contralateral to the insertion, in a patient with extensive inguinal burn injuries. CONCLUSIONS: Cross-over subclavian retrieval can be an alternative approach for retrieval of a lost guidewire, but it involves an increased risk of puncture-related complications such as pneumothorax.
Abstract: Anisocoria after blunt head trauma, associated with altered vigilance, is not unusually assumed to expanding intracranial mass lesion. Obvious signs of head-trauma and vomiting might strengthen this diagnosis. We report from an unconscious 15-year-old girl (Glasgow-Coma-Scale score 3) that showed these symptoms secondary after head-trauma due to alcohol intoxication but turned out to be misleading after cranial computed tomography (CT). Surprisingly, an artificial eye was found that previously remained undetected in clinical examination. Artificial eyes implemented after enucleation therapy in retinoblastoma or eye-trauma are nowadays perfectly fitting. Prehospital discrimination of artificial eyes and natural eyes might be difficult in comatose emergency patients. Neurological examination should check corneal reflex and manual palpation of the bulbus. Independent from anisocoria, patients presenting GCS 3 and head injury need rapid admission to CT-diagnostic, neurosurgical treatment respectively.
