[Severe Head Injury in Childhood: the Importance of Early Offensive Therapy]. / Závazné kraniotrauma v detském veku: význam vcasné ofenzivní terapie.

The case report presents the case of a five-year-old boy who fell off a scooter and sustained a blow to the left temporal region of his head. During a CT examination in the district hospital he suddenly showed a deterioration in the level of consciousness. Subsequent treatment along with transport to a specialized department were aimed at preventing secondary pathological changes and maintaining pressure-volume homeostasis of the brain. High-quality controlled ventilation with effective pharmacotherapy and gentle transport were essential. At the target specialized department, cerebral oedema in the left temporal region and aspiration in the right upper lung lobe were identified. The boy was extubated after 6 hours of controlled ventilation and discharged to an intermediate care bed two days later without any serious consequences. Key words: cerebral oedema, haemodynamic swelling, severe head injury.

[Fascia iliaca Block with General Anaesthesia vs. Subarachnoid Morphine Block in Total Hip Arthroplasty]. / Blokáda fascia iliaca s celkovou anestezií vs. subarachnoidální blokáda s morfinem u totální náhrady kycelního kloubu.

PURPOSE OF THE STUDY Many physicians believe that loco-regional anaesthesia and analgesia improve the postoperative course of patients indicated for total hip arthroplasty compared to general anaesthesia. However, there are many patients who refuse subarachnoid or epidural anaesthesia, or have contraindications or conditions making the use of such techniques impossible. An alternative option is the combination of general anaesthesia and a peripheral nerve blockade. The aim of this prospective randomized open-label clinical trial was to compare the efficacy and quality of postoperative analgesia between fascia iliaca block combined with general anaesthesia (GA) and subarachnoid anaesthesia with morphine and bupivacaine (SAB). MATERIAL AND METHODS After having obtained the ethics committee approval and the patients consent, a prospective, open-label, randomized trial was conducted in patients referred for total hip arthroplasty (THR). The GA group was administered ultrasound-guided fascia iliaca block with 40 ml of 0.25% bupivacaine solution after the induction of general anaesthesia. In the SAB group, subarachnoid blockade was performed with a mixture of 3 ml of 0.5% bupivacaine with 0.150 mg morphine prepared in the hospital pharmacy. Right after surgery the patients were taken to the ICU for 24 hours, after which they were transferred to a general ward. In addition to vital signs monitoring, pain intensity using a 0-10 numeric rating scale (NRS), first morphine administration at NRS >4, total morphine consumption and potential adverse effects were observed over the period of 72 hours. RESULTS There was no statistical difference between the GA (14 persons) and the SAB (14 persons) group in demographic parameters, time to first morphine administration (10 hrs vs. 19 hrs, p=0.10), number of persons with no need for morphine after surgery (5 vs. 7), tingling sensation (1 vs. 0) or numbness of the limb (0 vs. 1). There was no difference in cardiorespiratory parameters or side effects of therapy. In neither case was there respiratory depression or delayed rehabilitation. No patient developed delirium after surgery, and no patient reported dissatisfaction with pain management. DISCUSSION The fascia iliaca block and subarachnoid anaesthesia using local anaesthetic with opioid addition have been repeatedly published for patients after total hip arthroplasty, but this study is unique by comparing the two methods. The study added a new piece of knowledge to the findings of several recent meta-analyses on the comparable outcomes of general and subarachnoid anaesthesia for hip replacement in the perioperative period. CONCLUSIONS If subarachnoid anaesthesia cannot be used in hip arthroplasty, general anaesthesia with fascia iliaca block provides comparable analgesia and quality of postoperative course. Key words: total hip arthroplasty, general anaesthesia, fascia iliaca block, subarachnoid anaesthesia, postoperative analgesia, postoperative course.

Intra-arrest formation of right-heart thrombi -- a case illustrated by real-time ultrasonography.

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

[Current cooling methods for induction of mild hypothermia in cardiac arrest survivors]. / Soucasné ochlazovací metody pro indukci mírné hypotermie po srdecní zástave.

Induction of mild therapeutic hypothermia early after return of spontaneous circulation improves prognosis of cardiac arrest survivors. Rapid cooling of the patients and correct maintainance of the target therapeutic temperature followed by controlled slow rewarming can be achieved by several noninvasive and invasive methods of various efficacy. Elementary and the most frequently used methods are surface cooling via ice-packs and rapid intravenous administration of cold crystaloids. Mattress cooling systems and facilities for endovascular cathether-cooling are more sophisticated, manageable and ensure more precise titration of therapeutic temperature. Cooling caps and helmets leading to selective head cooling can be used as the complementary techniques. Several other methods are too instrumentation-intensive, too invasive or investigated in animal experiments only. Anyway, near future may bring a rapid development of new effective and safe cooling systems.

Novel patterns of left ventricular mechanical activity during experimental cardiac arrest in pigs.

We conducted an experimental study to evaluate the presence of coordinated left ventricular mechanical myocardial activity (LVMA) in two types of experimentally induced cardiac arrest: ventricular fibrillation (VF) and pulseless electrical activity (PEA). Twenty anesthetized domestic pigs were randomized 1:1 either to induction of VF or PEA. They were left in nonresuscitated cardiac arrest until the cessation of LVMA and microcirculation. Surface ECG, presence of LVMA by transthoracic echocardiography and sublingual microcirculation were recorded. One minute after induction of cardiac arrest, LVMA was identified in all experimental animals. In the PEA group, rate of LVMA was of 106+/-12/min. In the VF group, we identified two patterns of LVMA. Six animals exhibited contractions of high frequency (VFhigh group), four of low frequency (VFlow group) (334+/-12 vs. 125+/-32/min, p<0.001). A time from cardiac arrest induction to asystole (19.2+/-7.2 vs. 7.3+/-2.2 vs. 8.3+/-5.5 min, p=0.003), cessation of LVMA (11.3+/-5.6 vs. 4.4+/-0.4 vs. 7.4+/-2.9 min, p=0.027) and cessation of microcirculation (25.3+/-12.6 vs. 13.4+/-2.4 vs. 23.2+/-8.7 min, p=0.050) was significantly longer in VFlow group than in VFhigh and PEA group, respectively. Thus, LVMA is present in both VF and PEA type of induced cardiac arrest and moreover, VF may exhibit various patterns of LVMA.

[Knowledge level of cardiopulmonary resuscitation in secondary school students of non-medical specialisation in the Czech Republic]. / Uroveni znalostí studentu stredních nezdravotnických skol o neodkladné resuscitaci v Ceské republice.

BACKGROUND: Knowledge of cardiopulmonary resuscitation (CPR) is essential part of the first aid skill. Constant attention is given to education in CPR mainly among adolescents. The aim of our epidemiological study was to asses the actual level of theoretical knowledge in CPR. METHODS AND RESULTS: We have developed a simple questionnaire including 17 items with 4 possible answers, just one correct. The questionnaire was distributed to students of middle schools excluding those with medical specialisation. Total 796 students from 26 classrooms participated, 784 (98.5%) of questionnaires could be used for evaluation. Excluding the knowledge in the purpose of resuscitation mask and telephone number of Emergency service, the number of correct answers was below 30%, even in items, which did not change for many years (position of the victim's body during resuscitation, frequency of artificial ventilation). CONCLUSIONS: Our results demonstrate that in spite of the effort to increase the level of knowledge in CPR in laymen, the actual level of knowledge is low and more frequent repetition of courses should be considered. In the future, we shall evaluate the effectiveness of new educational film.

[Alcohol, unintentional injuries and violence against emergency health care workers]. / Alkohol, neúmyslne zpusobená poranení a násilí vuci záchranárum.

Epidemiological data about unintentional injuries under the influence of alcohol are presented. Moreover, the violence against emergency health care workers in this country succeeds mainly the alcohol abuse. The taxation of alcoholic beverages should be increased. The availability of alcohol should be restricted (e.g. during sporting events), and the principles of European Alcohol Action plans should be implemented.

[Adverse hemodynamic changes during laparoscopic cholecystectomy and their possible suppression with clonidine premedication. Comparison with intravenous and intramuscular premedication]. / Nezádoucí hemodynamické zmeny behem laparoskopických cholecystektomií a moznost jejich potlacení clonidinem v premedikaci. Srovnání intravenózní a intramuskulární premedikace.

Laparoscopic cholecystectomies have adverse haemodynamic effects which limit their use in risk patients with heart disease. This applies in particular to significant hypertension. The etiology is analysed in detail in a review of the literature. The authors confirmed in their work involving 21 patients the incidence of these effects and tried to suppress them by premedication with clonidine (CATAPRESAN, Boehringer). 21 patients were given 0.15 mg clonidine in an infusion 15 minutes before operation and 21 patients 0.15 mg clonidine by the i.m. route 60-90 min. before operation. Standard anaesthesia was administered. A highly significant drop in the incidence of hypertension was recorded during operation for systolic pressure (p < 0.001) after both ways of administration, as well as of diastolic pressure (p < 0.01 for intravenous and p < 0.05 for intramuscular premedication). Premedication with intravenous clonidine can be recommended as a routine procedure before laparoscopic cholecystectomies.

The practice of therapeutic mild hypothermia in cardiac arrest survivors in the Czech republic.

BACKGROUND: The proper performance of therapeutic mild hypothermia (TH) in cardiac arrest survivors is a prerequisite for achieving the best possible outcome. We analyzed the recent technical issues of in-hospital TH practices in the Czech Republic. METHODS: As the second project of the PRE-COOL (Pre-hospital Cooling in Cardiac Arrest Patients) working group, we compiled the directory of all non-surgical intensive care units (ICUs) in the Czech republic. A head physician of every ICU was provided a structured questionnaire in October 2008. RESULTS: From a total of 487 ICUs that were sent the questionnaire, 41.5% responded. We analyzed the responders that provide early post-resuscitation care, including TH (N=90). The site of TH initiation was most frequently an ICU bed (93.3%). A broad TH indication irrespective of the initial rhythm, cardiac arrest location or the presence of witnesses was reported by 48.9% of the responders. Up to 81.1% of the responding ICUs did not exclude from TH therapy patients who were developing post-resuscitation shock. Complex neuroprotective and cardioprotective approaches (TH, urgent coronary intervention, control of glycemia and early goal-directed hemodynamic support) were practiced at 52.2% of the ICUs. Of the responders, 54.4% cooled patients for 24 hours. The most frequently used cooling techniques were surface cooling with ice packs (88.9%) and intravenous cold infusion (84.4%). CONCLUSION: The survey revealed the recent practice of TH management of cardiac arrest survivors in the Czech republic. The modes of TH practice were different in many aspects, and unifying the basic components is advisable.

Diversity of metabolic patterns in human brain tumors: enzymes of energy metabolism and related metabolites and cofactors.

Biopsies from 15 human gliomas, five meningiomas, four Schwannomas, one medulloblastoma, and four normal brain areas were analyzed for 12 enzymes of energy metabolism and 12 related metabolites and cofactors. Samples, 0.01-0.25 microgram dry weight, were dissected from freeze-dried microtome sections to permit all the assays on a given specimen to be made, as far as possible, on nonnecrotic pure tumor tissue from the same region. Great diversity was found with regard to both enzyme activities and metabolite levels among individual tumors, but the following generalities can be made. Activities of hexokinase, phosphorylase, phosphofructokinase, glycerophosphate dehydrogenase, citrate synthase, and malate dehydrogenase levels were usually lower than in brain; glycogen synthase and glucose-6-phosphate dehydrogenase were usually higher; and the averages for pyruvate kinase, lactate dehydrogenase, 6-phosphogluconate dehydrogenase, and beta-hydroxyacyl coenzyme A dehydrogenase were not greatly different from brain. Levels of eight of the 12 enzymes were distinctly lower among the Schwannomas than in the other two groups. Average levels of glucose-6-phosphate, lactate, pyruvate, and uridine diphosphoglucose were more than twice those of brain; 6-phosphogluconate and citrate were about 70% higher than in brain; glucose, glycogen, glycerol-1-phosphate, and malate averages ranged from 104% to 127% of brain; and fructose-1,6-bisphosphate and glucose-1,6-bisphosphate levels were on the average 50% and 70% those of brain, respectively.