J. Horter

Paramedian access to the epidural space: the optimum window for ultrasound imaging

STUDY OBJECTIVE To establish a useful ultrasonic approach to the epidural space so as to optimize pre-puncture diagnostics. DESIGN Prospective study. SETTING University clinic. PATIENTS 60 participants (19 to 34 years of age), 40 healthy volunteers (20 male, 20 female) and 20 parturients. INTERVENTIONS Ultrasound scanning of the lumbar spine was performed at the L(3)-L(4) vertebral interspace. Three ultrasound planes were employed: the transverse, median, and paramedian longitudinal approaches. MEASUREMENTS We compared the width of the ultrasound-permeable area in the median and paramedian planes and assessed the visibility of the epidural space and its surrounding structures. MAIN RESULTS In the paramedian plane, the permeable window was larger (p < 0.001) than in the median approach. The visibility of the ligamentum flavum (p < 0.0001), dura mater (p < 0.0001), and cauda equina (p < 0.0001) was significantly higher. Pulsation of epidural vessels could be observed more frequently (p < 0.0001) in the paramedian plane. CONCLUSIONS The longitudinal paramedian plane provided information about the epidural space depth in excellent imaging quality. The additional information might be beneficial in epidural anesthesia and in other clinical specialties (e.g., neurosurgery, trauma care).

Suprathel(®) for severe burns in the elderly: Case report and review of the literature.

Large burns in aged patients are common and treatment often reveals challenging. Cardiovascular complications significantly contribute to the unfavorable prognosis in this group of high-risk patients. Pain medication and sedation can negatively influence cardiovascular stability. Suprathel(®) is well-known for its almost pain free application and reduction of dressing change intervals, and thus lowers the demand for potentially harmful analgesics and sedatives. We present the case of an 81-year-old patient with 51% of total burned body surface area (ABSI=12), who was completely treated with Suprathel(®). Despite a predicted mortality of more than 80%, the patient survived and was discharged home without significant handicaps 69 days after burn. We hypothesize that Suprathel(®) beneficially contributed to the favorable clinical course of this critical patient as less frequent wound-dressing changes did not induce additional pain or sedative medication and thus improved cardiovascular stability.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. MATERIAL AND METHODS A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. RESULTS 17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. CONCLUSION While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Aktuelle Standards in der VerbrennungsmedizinCurrent standards in treatment of burns

ZusammenfassungThermische Traumata können zu lebensbedrohlichen Schädigungen und zu bleibenden funktionellen und ästhetischen Verletzungsfolgen führen. Eine optimale Therapie verbessert die Prognose für den Verletzten und kann signifikante Langzeitschäden abwenden. Die optimale Prognose vor Augen, beginnt multidisziplinäre Zusammenarbeit bereits in der präklinischen Versorgung, während der Akuttherapie im Schwerbrandverletztenzentrum sowie in der sich anschließenden Rehabilitationsbehandlung und rekonstruktiven Phase und sollte aktuellen Standards der Verbrennungsmedizin folgen. Stetige Weiterentwicklungen dieser Standards der letzten Jahre betreffen dabei jede Phase der Verbrennungsbehandlung: Während in der präklinischen Behandlung das vornehmliche Augenmerk auf Temperaturerhalt und Volumensubstitution gelegt wird, ist die chirurgische Behandlung durch Innovationen wie permanente und temporäre Dermisersatzmaterialien und enzymatische Wunddébridements geprägt. In der Phase der Rehabilitation schwerbrandverletzter Patienten ist der Stellenwert einer multiprofessionell organisierten stationären Behandlung inzwischen unbestritten und soll in engem Kontakt mit rekonstruktiv-chirurgisch tätigen Teams erfolgen, um rechtzeitig funktionelle Limitation zu beseitigen. Wenn die Akutphase einer Verbrennung überwunden ist, bleiben deren Folgen oft ein Leben lang behandlungsbedürftig. Spezialisierte Sprechstunden sind notwendig, um in dieser Phase bedarfsgerechte und prognoseverbessernde konservative und stellenweise chirurgische Therapieverfahren rechtzeitig anbieten zu können.AbstractThermal trauma can lead to life-threatening damage and permanent functional and aesthetic sequelae of injuries. The optimal therapy improves the prognosis for injured persons and can prevent significant long-term damage. With the optimal prognosis in mind, the multidisciplinary cooperation begins during the preclinical care, during the acute treatment in a center for severe burn injuries and in the subsequent rehabilitation therapy and reconstruction phase. This should be carried out according to the current standards in the treatment of burns. Continuous further development of these standards in recent years have involved all phases of burn treatment: whereas in the preclinical treatment the main emphasis is on maintaining temperature and volume substitution, the surgical treatment is characterized by innovations, such as permanent and temporary dermal replacement materials and enzymatic wound debridement. In the rehabilitation phase of severely burned patients, the importance of a multiprofessionally organized inpatient treatment is nowadays undisputed and should be carried out in close cooperation with reconstructive surgery teams, for a timely resolution of functional limitations. When the acute phase of burn injuries has been overcome the sequelae often remain in need of treatment for life. Specialized medical consultation is necessary during this phase for timely provision of adequate conservative and sometimes surgical therapy procedures to improve the prognosis.

Aktuelle Standards in der Verbrennungsmedizin@@@Current standards in treatment of burns: Akuttherapie, Rehabilitation und Rekonstruktion idealerweise aus einer Hand@@@Acute therapy, rehabilitation and reconstruction ideally under one roof

ZusammenfassungThermische Traumata können zu lebensbedrohlichen Schädigungen und zu bleibenden funktionellen und ästhetischen Verletzungsfolgen führen. Eine optimale Therapie verbessert die Prognose für den Verletzten und kann signifikante Langzeitschäden abwenden. Die optimale Prognose vor Augen, beginnt multidisziplinäre Zusammenarbeit bereits in der präklinischen Versorgung, während der Akuttherapie im Schwerbrandverletztenzentrum sowie in der sich anschließenden Rehabilitationsbehandlung und rekonstruktiven Phase und sollte aktuellen Standards der Verbrennungsmedizin folgen. Stetige Weiterentwicklungen dieser Standards der letzten Jahre betreffen dabei jede Phase der Verbrennungsbehandlung: Während in der präklinischen Behandlung das vornehmliche Augenmerk auf Temperaturerhalt und Volumensubstitution gelegt wird, ist die chirurgische Behandlung durch Innovationen wie permanente und temporäre Dermisersatzmaterialien und enzymatische Wunddébridements geprägt. In der Phase der Rehabilitation schwerbrandverletzter Patienten ist der Stellenwert einer multiprofessionell organisierten stationären Behandlung inzwischen unbestritten und soll in engem Kontakt mit rekonstruktiv-chirurgisch tätigen Teams erfolgen, um rechtzeitig funktionelle Limitation zu beseitigen. Wenn die Akutphase einer Verbrennung überwunden ist, bleiben deren Folgen oft ein Leben lang behandlungsbedürftig. Spezialisierte Sprechstunden sind notwendig, um in dieser Phase bedarfsgerechte und prognoseverbessernde konservative und stellenweise chirurgische Therapieverfahren rechtzeitig anbieten zu können.AbstractThermal trauma can lead to life-threatening damage and permanent functional and aesthetic sequelae of injuries. The optimal therapy improves the prognosis for injured persons and can prevent significant long-term damage. With the optimal prognosis in mind, the multidisciplinary cooperation begins during the preclinical care, during the acute treatment in a center for severe burn injuries and in the subsequent rehabilitation therapy and reconstruction phase. This should be carried out according to the current standards in the treatment of burns. Continuous further development of these standards in recent years have involved all phases of burn treatment: whereas in the preclinical treatment the main emphasis is on maintaining temperature and volume substitution, the surgical treatment is characterized by innovations, such as permanent and temporary dermal replacement materials and enzymatic wound debridement. In the rehabilitation phase of severely burned patients, the importance of a multiprofessionally organized inpatient treatment is nowadays undisputed and should be carried out in close cooperation with reconstructive surgery teams, for a timely resolution of functional limitations. When the acute phase of burn injuries has been overcome the sequelae often remain in need of treatment for life. Specialized medical consultation is necessary during this phase for timely provision of adequate conservative and sometimes surgical therapy procedures to improve the prognosis.

Aktuelle Standards in der Verbrennungsmedizin

ZusammenfassungThermische Traumata können zu lebensbedrohlichen Schädigungen und zu bleibenden funktionellen und ästhetischen Verletzungsfolgen führen. Eine optimale Therapie verbessert die Prognose für den Verletzten und kann signifikante Langzeitschäden abwenden. Die optimale Prognose vor Augen, beginnt multidisziplinäre Zusammenarbeit bereits in der präklinischen Versorgung, während der Akuttherapie im Schwerbrandverletztenzentrum sowie in der sich anschließenden Rehabilitationsbehandlung und rekonstruktiven Phase und sollte aktuellen Standards der Verbrennungsmedizin folgen. Stetige Weiterentwicklungen dieser Standards der letzten Jahre betreffen dabei jede Phase der Verbrennungsbehandlung: Während in der präklinischen Behandlung das vornehmliche Augenmerk auf Temperaturerhalt und Volumensubstitution gelegt wird, ist die chirurgische Behandlung durch Innovationen wie permanente und temporäre Dermisersatzmaterialien und enzymatische Wunddébridements geprägt. In der Phase der Rehabilitation schwerbrandverletzter Patienten ist der Stellenwert einer multiprofessionell organisierten stationären Behandlung inzwischen unbestritten und soll in engem Kontakt mit rekonstruktiv-chirurgisch tätigen Teams erfolgen, um rechtzeitig funktionelle Limitation zu beseitigen. Wenn die Akutphase einer Verbrennung überwunden ist, bleiben deren Folgen oft ein Leben lang behandlungsbedürftig. Spezialisierte Sprechstunden sind notwendig, um in dieser Phase bedarfsgerechte und prognoseverbessernde konservative und stellenweise chirurgische Therapieverfahren rechtzeitig anbieten zu können.AbstractThermal trauma can lead to life-threatening damage and permanent functional and aesthetic sequelae of injuries. The optimal therapy improves the prognosis for injured persons and can prevent significant long-term damage. With the optimal prognosis in mind, the multidisciplinary cooperation begins during the preclinical care, during the acute treatment in a center for severe burn injuries and in the subsequent rehabilitation therapy and reconstruction phase. This should be carried out according to the current standards in the treatment of burns. Continuous further development of these standards in recent years have involved all phases of burn treatment: whereas in the preclinical treatment the main emphasis is on maintaining temperature and volume substitution, the surgical treatment is characterized by innovations, such as permanent and temporary dermal replacement materials and enzymatic wound debridement. In the rehabilitation phase of severely burned patients, the importance of a multiprofessionally organized inpatient treatment is nowadays undisputed and should be carried out in close cooperation with reconstructive surgery teams, for a timely resolution of functional limitations. When the acute phase of burn injuries has been overcome the sequelae often remain in need of treatment for life. Specialized medical consultation is necessary during this phase for timely provision of adequate conservative and sometimes surgical therapy procedures to improve the prognosis.