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Surgical Observations and Their Consequences: Vorgelegt in der Sitzung vom 18. November 1989 PDF

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SSiittzzuunnggssbbeerriicchhttee ddeerr HHeeiiddeellbbeerrggeerr AAkkaaddeemmiiee ddeerr WWiisssseennsscchhaafftteenn MMaatthheemmaattiisscchh--nnaattuurrwwiisssseennsscchhaaffttlliicchhee KKllaassssee JJaahhrrggaanngg 11999900,, 33.. AAbbhhaannddlluunngg F. Linder 1. Steffens M. Ziegler Surgical Observations and Their Consequences With 6 Figures Vorgelegt in der Sitzung vom 18. November 1989 Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Fritz Linder Chirurgische U niversitatsklinik 1m Neuenheimer Feld 110 6900 Heidelberg Joachim Steffens Manfred Ziegler Urologische Universitatsklinik 6650 Homburg/Saar ISBN-13: 978-3-540-52363-5 e-ISBN-13: 978-3-642-46701-1 DOl: 10.1007/978-3-642-46701-1 LC card number: 12-8903 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only per mitted under the provisions of the German Copyright Law of September 9, 1965, in its current version, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1990 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 1YPesetting: K + V Fotosatz GmbH, Beerfelden 2125/3140-543210 Contents F. LINDER Accidental Hypothermia 7 F. LINDER, 1. STEFFENS, M. ZIEGLER Renin Secreting Tumors of the Kidney with Secondary Hypertension 12 - 245 - Accidental Hypothermia * F. LINDER The study of accidental hypothermia has intensified, especially during World War II. Pilots who had to bailout of their planes into the sea lost their normal body temperature very rapidly. At a water temperature of 16°C, the core tempera ture, fell to below 30 °C after immersion for 1 - 5 h, and there was the danger of cardiac arrest. In September 1940, pilots picked up still alive from the North Sea were often unable to climb out of the water into the life boat or plane because general stiffness had reduced their mobility. Precise data were obtained by means of animal experiments in many physiological institutes - not to mention the shocking icewater tests on willing and not-so-willing persons. It is well known that immersion reduces the body temperature 15 to 20 times faster than a dry cold atmosphere. This is the reason why BIGEWW and LEWIS applied the wet method to produce hypothermia, e.g., in a bathtub filled with cold water, in early open heart surgery. The few cases that have survived after an immersion of longer duration are fascinating. An outstanding example is the history of an Icelandic fisherman who capsized and who reached the shore after swimming in seawater of 5°C for 5 h. The explanation for this lucky event was probably the good insulation provided by the adipose subcutaneous tissue. The case has been described in the Icelandic Journal of Physiology. Another dramatic accident happened to a 4-year-old boy who broke through the crystal clear, but very thin ice of Lake Steinhude near Hannover. An emergen cy helicopter detected the boy in his green wintersuit floating directly under the ice about 50 m from the hole. The copilot went down on a rope, cracked the ice with his boots and snatched the boy out of the water (23 min after the alarm). On the plane the water was expelled from his lungs, followed by intubation, respiration and cardiac massage. At the Intensive Care Unit of the Hannover Medical School Hospital, the rectal temperature was found to be below 20°C. Within 88 min after respiratory and cardiac arrest, however, the boy revived after external application of warmth. There was complete recovery without any obser vable brain damage. * Lecture, held at the Anglo-American Conference, Reykjavik, Iceland, August 22, 1988. - 247 - 8 F. Linder DEU'fSCHES ARCHIV KLINIS'CIIE MEDICIN II. Ueobllchfungen Uber die KlJrpertf.mperatur Bttrunkener. Voo Dr. J. J. Reineke 10 lIambar" IU; IJlIl I K'I' V UN DB. H. v.·ZIEMSSEN, UNO Du. lo'. A. ZENKElt, fICo •• 1)111. ....m CltlJ .. cHKM .KLUUK l'liu,U", "':11. "i.TUuLUouIlCUIIo" &1'14 nUl. a IN 1I0t/CII~N. IN ~III.AIIO ~N. SECHSZEHNTER BAND. MI'!, 23 110LZ:lt:IlNI'l"l'.I::~ UNO b 'fA l-'}o; LN. _ . ... _.-.... ...---- LEIPZIG, V E It LAG VON l<'. C. W. v 0 G 1-: L. t 87:;. - 248 - Accidental Hypothermia 9 Naturally, the history of hypothermia is very long. As long as 100 years ago such conditions were analyzed by accurate measurements. In the German literature, a medical officer of the Hamburg Police described a totally drunk per son who was found unconscious in the street in 1875. The air temperature was + 1 °C and the person's rectal temperature was 24°C at 8. a. m., which rose to 37.8°C within 24 h. The report was enriched by the case histories of 17 other alcoholics with rectal temperatures of between 30° and 34°C, with 12 survivors (Fig. 1). I assume that many comparable reports could be found in the medical literature of other nations as well. We all know of the terrible losses that have occurred during various wars as a result of hypothermia, losses that were often increased by injury and hunger. Of the 500000 to 800000 French and allied troops that Napoleon led to Moscow, only 20000 to 40000 lancers returned to central Europe. Even worse was the Ger man experience during December and January 1944-1945 when, according to the best estimates, almost 2000 men per day suffered lethal or non-lethal cold in juries. Now let us return to more peaceful accidents. In the European Alpine coun tries numerous accidents have also been observed as a result of cold weather. Within 5 years, Austria alone had more than 500 victims from avalanches, creavasses, or sudden cold weather conditions. Mountaineers who have lost their core temperature through exposure for hours should not be mobilized actively or passively because of the danger of the temperature dropping again when the colder blood from the vasoconstricted periphery returns to the heart. Tourniquets to stop bleeding in fractures or open wounds can also lead to sudden cardiac death due to the same drop in tempera ture described in victims who were dug out of a snowy cave and who then tried active walking. In the outdoors, the following ten factors (Table 1) may be beneficial to hypothermia victims because they may prevent further loss of body temperature. Table 1. Some factors in the field treatment of accidental hypothermia 1. Shelter against wind 2. Change wet for dry clothes 3. Warm wet pack ings from hot water bottles on breast and abdomen (HIBLER) 4. Do not rub frozen extremities with snow, but with warm towels 5. Warm the whole patient in normal room temperature 6. Use plastic bags 7. Adipose people are better insulated 8. Watch cardiac function (disturbances < 30°C) 9. Psychological factors and fatigue are of some importance 10. Black people are 4 - 6 times higher endangered - 249 - 10 F. Linder Table 2. Deep accidental hypothermia: rewarming with extracorporal methods in 14 pa tients (Clinic of Cardiovascular Surgery, Prof. ALTHAUS) Crevasse Exposure Avalanche/ Total (suicide) immersion Survival 8 2 0 10 Exitus 2 3 6 (Cranial injury) (Reanimation unsuccessful) Table 3. Deep accidental hypothermia: experience in Berne (Prof. ALTHAUS) Treatment of 16 cases (6 deaths) - Age: 13 - 56 years Rectal temperature: 18° - 25°C Cardiac arrest 14 patients Serious low output syndrome 2 patients Cranial injuries with 2 deaths Therapeutic technique No. cases Extracorporeal warming without sternotomy 13 Extracorporeal warming with sternotomy Thoracotomy, mediastinal lavage Peritoneal dialysis The initial treatment can be given in a wind shelter, a mountain hut or, even better, in an intensive care unit of a hospital with all the proper equipment and a heliport. Peritoneal warm dialysis with two catheters in the abdomen is (or was) a potential method of rewarming the body core. Since 1967 (DAVIS and Moss), however, the first experimental and human experiences with extracorporal blood warming (connected to iliac artery and vein) has demonstrated that the rewarming speed with a heart exchanger can be 4 times faster than with external methods. The Swiss University Hospital in Berne has a collection of cases. A con siderable number (16) of their severe hypothermic patients were saved by the heart-lung machine (Tables 2 and 3). However, heparinization is a contraindica tion for patients with brain lesions or other serious injuries. In conclusion, accidental hypothermia is a lifethreatening condition that re quires the quickest transportation possible to a place with optimal therapeutic facilities. It is clear that one's geographic location on the globe alone, with its variation in heights, is no absolute protection against sustaining a cold injury. - 250 - Accidental Hypothermia 11 Let me just add one gruesome footnote (or fingernote) which also contains some other information on hypothermia. This extraordinary case is part of the criminal scene. Last November, the owner of a Dutch supermarket chain was kid napped by a single person and shot within the next 24 h. His corpse was then hid den in a shallow hole. Before this provisional interment, a little finger was cut off and preserved with ice cubes in a vacuum flask. At intervals, the gangster provid ed the relatives with some belongings of the victims. Also included was the iced finger as definitive proof that his hostage was still alive. No pathologist or foren sic specialist was certain whether the tissue was taken from a living or from a dead individual. References ALTHAUS U, AEBERHARD P, SCHUPBACH P, NACHBUR BH, MUHLEMANN W (1982) Management of profound accidental hypothermia with cardiorespiratory arrest. Ann Surg 195:492 BERGHOLD F (1982) Lawinenunfall - Richtige Erste Hilfe entscheidet uber Leben und Tod. Notfallmedizin 8: 1503 BIGELOW WG (1984) Cold hearts and vital lessons. Am ColI Surg Bull 69:12 BRENDEL W, MULLER C, MESSMER K, REULEN HJ (1968) Der klinische Tod in Hypother mie. Z Gesamte Exp Med 146:189 DAVIES DM, MILLAR EJ, MILLER IA (1967) Extracorporeal bloodwarming. Lancet I: 1036 Deutsche Gesellschaft zur Rettung Schiffbruchiger (1982) 2. Symposion, Cuxhaven: Un terkuhlung im Seenotfall FRITZ K-W, KASPERCZYK W, GALASKE R (1988) Erfolgreiche Reanimation bei akzidentel ler Hypothermie nach Ertrinkungstod. Anaesthesist 37:331 HARNETT RM, O'BRIEN EM, SLAS FR, PRUITT JR (1980) Initial treatment of profound accidental hypothermia. Aviat Space Environ Med 5:680 KAHLE W, BURCHARD E (1984) Dberleben in der KlUte: Entstehung allgemeiner KlUte schaden und therapeutischer MaBnahmen. Dtsch Arztebl KLOSS T (1983) Pathophysiologie, Diagnose und Behandlung akzidenteller Unterkuhlung. Anasth Intensivmed 18: 199 LINDER F (1987) Medical services in wintertime. Med Corps int 6:29 Moss JF (1986) Accidental hypothermia. Surgery 162:501 NEUREUTHER G, FLORA G (1978) Kalteschaden, Behandlung der allgemeinen Unterkuh lung und ortlichen Erfrierungen. Notfallmedizin 4: 103 OTFLEIGSSON OJ (1980) Cold water therapy in burns. Z Pist Chir REINCKE JJ (1985) Beobachtungen uber die Korpertemperatur Betrunkener. Deutsches Archiv fUr Klinische Medizin, Vol 6. Vogel, Leipzig SPLlTTGERBER FH, TALBERT J, SWEEZER WP, WILSON RF (1986) Partial cardiopulmonary bypass for core rewarming in profound accidental hypothermia. Am Surg 52:407 THAUER R, BRENDEL W (1962) Hypothermia. Prog Surg 2:73 TURINA M, HOSSLI G (1976) Successful rewarming with heart-lung machines. In: Lawinen. Jurist-Verlag, Zurich, Swiss Medical Committee (1. V. R.) - 251 - Renin Secreting Tumors of the Kidney with Secondary Hypertension *. ** F. LINDER, J. STEFFENS, M. ZIEGLER For a long time a relation between the blood circulation and the function of kidneys has been suspected. An early classic example can be found in the museum of the Guys Hospital in London where BRIGHT 1836 anticipated a causal relation and preserved a hypertrophic heart and two shrivelled kidneys in the same specimen jar. They demonstrate what as we learnt much later the first etiological connection between renal disease and hypertension. In 1898, TIGERSTEDT and BERGMANN in Stockholm succeeded in showing that a pressor substance was pre sent in the kidneys of rabbits. They called it renin from its origin. Since the 1930's clinical experience has shown that certain bi- and unilateral renovascular diseases of different pathology, besides urinary strictures, can in duce systemic hypertension (Table 1). Guy's Hospital Reports 1, 1836 ( 338 ) CASES AND OBSERVATIONS, lLLUSTIU.TIVE O!" RENA.L DISEASE ACC0311,,,,.°IED WITH THE SECRETIO~ OF ALDUll!INOUS URINE, BY DR. BRIGHT. Fig. 1. BRIGHT 1836: Specimen of hypertrophic heart and shrivelled kidneys * Lecture in Edinburgh 1989 (RCSE). ** Dedicated to Wilhelm DOERR. - 252 -

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