[Pre-clinical management of shock patients]. / Präklinische Versorgung des Patienten mit Schock.

The preclinical diagnosis of shock is still based on the patient's history, the physical examination, the injury pattern and a few hemodynamic parameters available in the emergency set-up. The clinical picture is characterised by hypotension and tachycardia, tachypnoe and dyspnoea as well as cerebral impairment. Results from recent clinical trials indicate, that a adapted and specific therapeutic approach for the various shock forms is necessary. In case of traumatic hypovolemic-hemorrhagic shock it is of particular relevance if penetrating trauma and/or uncontrolled bleeding exists. Under these conditions an immediate definite surgical treatment is required ("scoop and run") and a moderate hypotension should be tolerated. ("treat and run"). Fluid substitution and therapy with catecholamines should be used conservatively. In all other forms of shock the treatment approach can and should be more aggressive in order to improve microvascular perfusion as early as possible. Besides adequate fluid resuscitation in a combination of crystalloid and colloid solutions catecholamines and-under specific circumstances-also vasopressin should be used. Of utmost importance in the pre-clinical management of patients in shock is the optimal selection of the centre that the patient is referred to in order to establish the fastest and best possible definite treatment for the patient.

[Emergency treatment of penetrating, combined thoracic- and abdominal injury. Pre-hospital i.v. fluid therapy]. / Erstversorgung einer penetrierenden 2-Höhlen-Verletzung Diskussion des präklinischen Managements der Volumentherapie.

We report the rare case of a penetrating, combined thoracic- and abdominal injury as a consequence of a farm work accident. During the recent years, a "treat and run" approach has been increasingly advocated as a time-saving way of treating penetrating injuries, constituting a compromise between the existing strategies of "scoop and run" (used mainly in the USA) and "stay and treat" (preferred in Central Europe). A prolonged rescue response time makes the treat and run approach impossible here. Immediate treatment at the accident site requires an appropriate provision of i.v. fluids. We examine the course of pre-hospital treatment of a trauma patient to illustrate the various approaches to i.v. fluid therapy in relation to rescue response time. However there are only a few studies with a real evidence. If "treat and run" is not possible, the outcome of patients with penetrating trauma can be influenced positively by moderate fluid therapy under continuous monitoring after having reached a constant, low mean arteria pressure (so called permissive hypotension).