[MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIK] [MUSIC] [MUSIC] >> Look here, professor, this patient was just brought here. >> What has happened to you? >> His comrades from the Grünwald Knights' Tournament brought him here. >> Well, I see, you just came here from the Knights' Tournament. >> Yes. It went a bit wrong. >> Are you in pain? >> Currently not so much. But can you remove the arrow, please? >> He seems to have a pulse. And he's talking, too. No, we cannot remove the arrow. Otherwise, we'd hurt you even more. We have to do it in the OR. And we have to remove his knight's armour, too. Please set off the trauma room alarm and notifiy the colleagues in the OR. >> No, no, I have to go back and fight on. >> Yes, you can do that later. >> Okay. I'll notify the colleagues and prepare everything. >> Yes. We'll be there soon. 31 00:01:44,420 --> 00:01:46,680
>> In Germany, penetrating wounds are found only among 5% of the causes for severe wounds. Compared to blunt injuries, increased numbers of resuscitations, states of shock, operations and higher mortality rates are observed. Only every second patient with an AIS score of 5 points survives. What comes into your mind when you see the following image? Here you see a clinical photograph after a penetrating wound to the thorax. When you have to assume that the thorax has been penetrated, you must by no means remove any foreign bodies. Otherwise, any possible tamponade effect would be suspended and very severe bleedings could occur. Removal of such penetrating foreign bodies always takes place in the OR. The air-tight occluding or joining of the puncture openings is also contraindicated, as it prevents pressure being relieved from the pleural cavity. The initial treatment of penetrating injuries is performed according to the ATLS criteria, just like in the case of blunt trauma. Airway stands for Airway displacement and according correction. Problems regarding breathing, such as a tension pneumothorax for example, should be relieved immediately. The patient should undergo an according infusion therapy. Furthermore, the neurological status should be determined and an according hypothermia should be considered. Here you can see a clinical photograph after penetrating injury in an attempted suicide. The patient tried to cut his throat with a large sword. In doing so, he opened up his larynx and therefore created an Airway problem. This photo shows the opened up larynx. Relieving the airways can be facilitated by the insertion of a tube in this case. Here you can see the intestine dwelling out after the suicide attempt with a sword. When a tension pneumothorax is clinically suspected, decompression should be undertaken immediately. These graphics schematically show the pathophysiological formation mechanism of a tension pneumothorax. It is clearly visible, how free air is pressed into the space between the lung and the pleura in the right thorax due to the valve mechanism. Therefore, the mediastinal organs are relocated to the left side. >> I want to go back to the fight. >> Well, he doesn't have an Airway or Breathing problem, as he is able to talk. >> The radial pulse is well palpable. >> We'll additionally perform a sonography. >> Yes. >> Please remove the arrow, I want to take revenge. >> You will be anaesthetised by a colleague and I will just take a look at... >> I don't want to be anaesthetised. I want to go back... >> We don't have a choice, >> we have to remove the arrow in the OR under anaesthesia. >> Yes. >> Because if we simply remove it, we wouldn't really know what is injured. You don't fit into the CT like this. >> Right, make it quick, get it out. >> Well. >> Can you see something? >> No, a pericardial tamponade is difficult in his case, but I don't see anything there. Let's check this side over there. His lung seems to have collapsed. In doubt, we have to assume a pneumothorax or a tension pneumothorax. Okay. >> Then, we go to the OR with you and remove the arrow there. >> Nonsense, simply put on a dressing and the show goes on. >> Now, let's transport him to the OR. You are going to anaesthetise me. >> Stay calm. >> Positioning just like a standard thoracotomy, like for a lung operation. And a double-lumen tube would be nice, Ms. von Matthey. And a perfusion has been administered. And then we cut off the arrow and remove it. >> Then we go to the OR, right? >> Yes. >> For the identification of free fluids in the stomach, >> the FAST examination is performed. FAST stands for Focused Assessment Sonography in Trauma and has been an integral part of Primary Survey according to ATLS since 2008. By means of FAST, abdominal or thoracic haemorrhages can be identified very quickly. These graphics exemplarily show the postion of the sonographic probe for FAST. The first probe points in the direction of the pericard, the second one towards the Morrison Pouch, the third one in the direction of the spleen and the fourth one towards the Douglas Cavity. Regarding the issue of volume therapy after penetrating injuries, the Bickell Study has provided us with groundbreaking insights. In this study, more than 1000 patients underwent follow-up examinations after penetrating injuries to the torso. Interestingly, it was shown that those patients, who underwent preclinical volume therapy, had and increase in mortality rate. Also the probability of postoperative complications was significantly increased in the group with preclinical volume therapy. As a conclusion, the additional application of preclinical volume therapy can be harmful in case of penetrating injuries. It has been shown that patients with circulatory arrest after penetrating trauma can benefit from open cardiac massage. [MUSIC] >> So, now. His lung suffered a minor injury, but only the upper part. The arrow can now be freely moved. After all, we have already cut off the external side earlier. Now, gently pull it backwards. We have to be careful now and make sure that it doesn't bleed. Okay, now we treat the lung, hand me the "whisk". And then, we excise the bullet holes, introduce a thoracic drainage and close the wound. You were lucky. These graphics schematically show the approach in case of an emergency thoracotomy. Spread out the left arm, perform an incision above the 4th. ICS abd open up the pericardium for direct cardiac massage. This photograph exemplarily shows the necessary instruments for an emergency thoracotomy. Please take care to use the accordingly large vascular clamps. Here you can see the necessary instruments for an emergency thoracotomy in the OR. The thorax spreader on the left side is designed to keep the thorax open. In case a bilateral thoracotomy is necessary, it can be performed by means of a Gigli saw, as shown on the left side, or with a Lebsche chisel, as shown on the right side. This intraoperative image exemplarily shows an emergency thoracotomy. You can clearly see, how a direct cardiac massage is performed. For the therapy of the present case, we initially recapitulate the clinical conditions. The patient is awake, responsive and has a GCS of 15. His respiration is uncritical and his circulatory flow is stable. Therefore, the arrow can be removed in the OR under visual control by means of a standard thoracotomy. Summing up, it can be stated that penetrating injuries are found among approximately 5% of patients with severe injuries in the Federal Republic of Germany. In countries with less restrictive weapon control laws, the incidence is considerably different. Preclinical volume therapy should be critically assessed. [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC]
