Aksesuar navikular kemik anatomik ve radiografik incelemelerde rastlantý sonucu bulunan asemptomatik bir varyasyondur. Fakat travmatize olduðu zaman hastanýn semptomlarýndan sorumlu olur. Musculus tibialis posterior tendonunun gerilmesi, ayaðýn ileri derecede pronasyonu, þiddetli plantar fleksiyon ve ayakla yapýlan spor aktiviteleri navicular kemiðin medialinde santralize akut veya kronik ayak aðrýsýna sebep olur. Aksesuar navikular varyasyonlarýnýn üç tipi vardýr. Tip I, m. tibialis posterior tendonu içinde bir sesamoiddir. Bu tip, tüm aksesuar navikular varyasyonlarýnýn %30'unu oluþturur. Tip II, 1-3 mm kalýnlýðýnda bir fibrokartilaginoz synchondrosis ile os naviculare ile birleþmiþtir. Bu kemikçik radyografilerde 8-12 mm boyunda, triangular veya kalp seklinde görülür. Tip III'de, "Kornuat navicular", aksesuar navicular bir kemik köprü ile medial kenarýndan os naviculare ile füzyon yapmýþtýr. Tip II ve Tip III aksesuar navikular varyasyonlarýnýn %70'ini oluþturur. Kronik, tekrarlayan travmalarýn ayakta injüri oluþturabilmesi ve tamda kolayca bir kýrýk ile karýþabilmesi gibi sebeplerle bu varyasyonun iyi tanýnmasýna ihtiyaç vardýr. Çalýþmamýzda; aksesuar navikularýn tipleri, normal populasyon ile kadýn ve erkeklerde görülme sýklýðý araþtýrýldý. Literatür bilgileri ile bu varyasyonun klinik önemi tartýþýldý.

The accessory navicular is usually considered an asymptomatic variation. In most anatomic and roentgenographic examination, this is an incidental finding. But when traumatized, it can become the cause of clinical symptoms. The tension of the posterior tibial tendon, forceful plantar flexion and/or pronation and the sporting activities made by the feet cause chronic or acute medial foot pain centered over the medial side of the navicular bone. There are three types of accessory navicular variations. Type I is a sesamoid bone in the substance of the posterior tibial tendon. This ossicle accounts for approximately 30% of all the accessory naviculars; Type II is united to the navicular bone by a cartilaginous or fibrocartilaginous synchondrosis with a 1-3 mm. On radiographs, this ossicle is triangular or heart shaped and approximately 8 mm x 12mm; Type III, "the corniate navicular", is fused to the navicular bone by a bony bridge with a prominent posteromedial margin. Tip II and Tip III account for 70% of all accessory naviculars. Identification of this variation is of importance because the injury may occur as a result of chronic repetitious trauma and the ossicle may easily be mistaken for a fracture. In our study; the incidence, the types and female/male percentages in population of the accessory navicular were investigated. Clinical importance of this variation was discussed by the knowledge of literature.

Amacýmýz kliniðimizde tedavi edilen olgulardaki vasküler yaralanmalarýn lokalizasyonunu, klinik bulgularýný, cerrahi tedavilerini ve sonuçlarýný tartýþmaktadýr. Eylül 1987 - Nisan 1996 tarihlerinde kliniðimize vasküler yaralanma nedeniyle baþvuran 87 hastaya ait kayýtlar retrospektif olarak deðerlendirildi. 87 hastada 91 arteriyel, 48 venöz yaralanma vardý. 91 arteriyel yaralanmanýn %49'u primer tamirle, %30'u safen interpozisyonu ile, %16'sý ligasyon uygulanarak, %3'ü protez greft ve %2'si safen anjioplasti ile onarýldý. Mortalite %4', ampütasyon oraný %4'dür. Damar yaralanmalarýnda erken taný ve tedavi hastanýn yaþamýnýn ve ilgili ekstremitenin kaybýnýn önlenmesi ve ekstremite fonksiyonlarýnýn korunmasý açýsýndan en önemli faktördür. Vasküler travmalarda kýsa yoldan tanýya ulaþýp en doðru tedavinin erken dönemde yapýlmasý gereklidir.

The aim of the study is to discuss the localizations, clinical pictures, surgical interventions and the results of our patients who suffered from vascular trauma. Between September 1987 and April 1996, 87 patients were admitted to our clinic. The records of the patients were retrospectively reviewed. 91 arterial and 48 venous traumas were encountered. Primary repair (49%), saphenous interposition (30%), ligation (16%), greft interposition (3%) and saphenous angioplasty (2%) were applied to 91 arterial injuries. The mortality rate was 4%. Amputation rate was 4%. Early diagnosis and treatment are the most important factors. Immediate diagnosis and early accurate treatment are mandatory.

Servikal vertebralarýn instabil olduðu durumlarda, özellikle travmalarda otolog kemik greftine ek olarak anterior plak kullanýlmasý güvenilir bir uygulamadýr. Operasyon kolaylýðý saðladýðý ve hastanede kalýþ sürelerini kýsalttýðý gibi, hastalarýn erken rehabilitasyonuna imkan vererek iyileþmenin hýzlanmasýný saðlar. Bu yazýda, Ankara Numune Hastanesi Beyin ve Sinir Cerrahisi Kliniði'nde 1990-1996 yýllarý arasýnda yapýlan 32 anterior servikal plak uygulamasý retrospektif olarak deðerlendirerek sunulmuþtur.

Anterior fixation of instability of the cervical spine with plate and bone grafts has been performed by combined plate and bone fusion since 1990. Synthes titanium plates have been used in all patients. In this paper patients were evaluated retrospectively and compared to the literature.

1986-1994 yýllarý arasýnda Çukurova Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalý'nda penetran kolon yaralanmasý nedeniyle opere edilen 48 olgu retrospektif olarak incelendi. Kolon yaralanmasý 30 (%62,5) olguda ateþli silah, 18 (%37,5) olguda delici kesici alet yaralanmasý sonucu oluþtu. Olgularýn 32 (%66,6)'sinde grade II, 5 (%10,4)'inde grade III, 8 (%16,7)'inde grade IV, 3 (%6,3)'ünde grade V yaralanma mevcuttu. Dokuz (%18,7) olguya primer sütür, 39 (%81,3) olguya kolostomi prosedürleri uygulandý. Kolon yaralanmasýna en sýk ince barsak yaralanmasý eþlik etmekte idi (%50). On (%20,8) olguda postoperatif komplikasyon geliþti. Yedi (%14,6) olgu exitus oldu. Kolon yaralanma derecesinin IV ve üzerinde olmasý Kolon Yaralanma Skoru (FKYS)'nun grade III olmasý, birlikte yaralanan organ sayýsýnýn 2 ve üzerinde olmasý, 3 ünite ve üzerinde kan transfüzyonu gereksinimi postoperatif komplikasyon riskini artýran parametreler olarak bulundu. Kolon yaralanma derecesi dýþýnda bu parametrelere ilave olarak PATÝ deðerini 30'un üzerinde olmasý ise mortalite açýsýndan önemli bulundu. Penetran kolon yaralanmalarýnda yukarýda sayýlan risk fraktürleri olmaksýzýn PATÝ deðeri 25'in altýnda FKYS grade I ve II olgularda primer sütür, PATÝ deðerinin 25'in üzerinde ve FKYS grade III olgularda kolostomi prosedürlerinin seçilmesinin uygun olacaðý düþüncesindeyiz.

In this study, 48 penetrating colon injuries treated between 1986-1994 in Çukurova University, School of Medicine, General Surgery Department were evaluated retrospectively. 30 (62.5%) cases had gunshot wounds, 18 (37.5%) had stab wounds. Colon Injury Scores (CIS) were as follows: 32 (66.6%) grade II, 5 (10.4%) grade III, 8 (16.7%) grade IV, 3 (6.3%) grade V. Nine (18.7%) cases were managed by primary repair, whereas 39 (81.3%) cases were treated by colostomy procedures. The small bowel was the most frequently injured organ in colonic injury patients (50%). The complication rate was 20.8 percent. The mortality rate 14.6percent. The parameters increasing the risk of morbidity were as follows: CIS equal or greater than grade IV, Penetrating Abdominal Trauma Index (PATI) score over 20, Flint Colon Injury Score (FCIS) grade III, concomitantly organ injuries more than 2, blood transfusion over 3 units. Additionally to these parameters (excluded CIS), we observed that PATI score over 30 was increasing the mortality rate. Penetrating colon injuries without risk factors listed above, PATI score under 25 and FCIS grade I-II, can be managed by primary repair. In cases PATI score was over 25 and FCIS grade III, we believe that choosing colostomy procedures to be appropriate.

Beyin omurilik sývýsý (BOS) fistülü, BOS'nýn araknoid, dura, kemik veya epitel dokuda defekt olduðu zaman subaraknoid mesafeden ekstra araknoid mesafeye kaçýþýdýr. Serebrospinal aks boyunca herhangi bir yerden olabilir, ancak sýklýkla rinore veya otore þeklinde görülür. BOS fistüllerinin %80'inin nedeni travmadýr. Kapalý kafa travmalarýnýn %2-5'inde görülür. Travmanýn ilk haftasýnda akut olarak baþlayacaðý gibi bazen, aylar veya yýllar sonrada gecikmiþ olarak baþlayabilir. Rinorelerin %85'i, otorelerin ise tamama yakýný bir hafta içinde kendiliðinden kesilir. BOS fistüllerinin en önemli komplikasyonu menenjittir. Kliniðimizde Ocak 1995 yýllarý arasýnda tedavi edilen 52 travmatik BOS fistülü olgusu retrospektif olarak deðerlendirilmiþtir. Hastalar 2-70 yaþ aralýðýnda olup, erkekler de üç kat fazla görülmüþtür. Trafik kazasý ve düþme en sýk travmatik nedenlerdir. Olgularýn %79'u konservatif tedaviye yanýt vermiþtir. Hastalarýn hepsine profilaktik antibiyotik verilmesine raðmen 11 hastada menenjit, 1 hastada abse görülmüþtür. Menenjite baðlý mortalite oraný %33.3'tür. Bu çalýþmadan profilaktik antibiyotik kullanýlmasýnýn menenjit oranýný deðiþtirmediði, negatif kültür oranýný ve özellikle Klebsiella menenjitinin yüksek oranda görülmesine neden olduðu sonucu çýkarýlmýþtýr.

Cerebro-spinal fluid (CSF) fistula is leakage of fluid from sub-arachnoidal to extra-arachnoidal spaces when there is a defect of arachnoidea, dura, bone or epithelial tissues. This leakage can be through all the cerebrospinal axis but generally seen as rhinorrhea or otorrhea. The etiology of CSF fistulas in 80 of cases is trauma. It can be seen in 2-5% of closed head injuries. It may be detected either in the posttraumatic first week or within months and years after trauma as well. 85% of rhinorrheas and nearly all of otorrheas interrupt spontaneously at the end of one week. Meningitis is the most important complication of CSF fistulas. 52 cases of traumatic CSF fistula which were treated in our department between January 1990-June 1995 were reviewed retrospectively. Age distribution of the patients were 2-70 years and male/female ratio was 3/1. The most frequent etiological factors were traffic accidents and falling traumas. 79% of patients treated conservatively and even though were under control of antibiotic therapy meningitis in 11 cases and cerebral abscess in 1 case were revealed. Mortality rate of meningitis was 33.3% in our series. In this study, we saw that there was no any effect of prophylactic antibiotic treatment to meningitis rates and Klebsiella was the most frequent organism in microbiological investigations of patients with meningitis.

Bu çalýþmada 1990-1995 yýllarý arasýndaki 5 yýllýk periyod içinde Ankara Numune Hastanesi Acil Cerrahi Servisinde tedavi edilen 57 travmatik kolon yaralanmak hasta retrospektif olarak incelendi. 57 hastanýn 23'ü (%40) ateþli silah yaralanmasý (ASY), 22'si (%39) delici kesici alet Yaralanmasý (DKAY) ve 12'si de (%21) künt travmaya baðlý kolon yaralanmasý idi. Hastalarýn 17'sinde (%30) sað kolon, 18'inde (%31) transvers kolon ve 22'sinde de (%39) sol kolon yaralanmasý tespit edildi. Hastalarýn 44'üne (%77) primer onarým (primer sütür ve/veya rezeksiyon + anastomoz), 13'üne de (%23) kolostomi uygulandý. Hastalar kolon yaralanmasýnýn lokalizasyonu, eþlik eden organ yaralanmasý, penetran abdominal travma indeksi (PATI), Colonic Injury Severity Scale (CISS), yaralanma ile ameliyat arasýnda geçen süre, hemodinamik durum ve tahmini kaybedilen kan miktarý gibi risk faktörlerine göre deðerlendirildi. Mortalite oraný %44 idi ve hemodinamik instabilite, uzun süre devam eden sok, yaralanma ile ameliyat arasýnda geçen sürede gecikme, yaralanan organ sayýsýnýn fazlalýðý prognozu etkileyen faktörler olarak tespit edildi.

In this study; The records of 57 patients with traumatic colon injuries treated at the Ankara Numune Hospital-Emergency Surgery Department during a 5 year period from 1990 to 1995, were retrospectively reviewed. Twenty-three patients of 57 (40%) had gunshot wounds, 22 (39%) had stab-wounds and 12 (21%) had blunt colonic injuries. Right colon injuries were found in 17 patients (30%), transverse colon injuries in 18 patients (31%), and left colon injuries in 22 patients (39%). Primary repair, including suture repair and resection with anastomosis, was performed in 44 patients (77%) and colostomy in 13 (23%). Patients were evaluated according to the risk factors such as location of colonic injury, associated visceral injuries, penetrating abdominal trauma index (PATI), colonic injury severity scale (CISS), the time from injury operation, hemodynamical status and estimated blood loss. Mortality rate was 14% and hemodynamic instability, long acting shock, delaying time between injury and operation, and multiple visceral injuries were found co-efficient factors to prognosis.

Künt ve penetran abdominal travmalarda, negatif laparotominin kabul edilebilirliliðinin, ne oranda olmasý gerektiði halen tartýþýla gelen bir konudur. Özellikle organ yaralanmasý bulgularýnýn minimal olduðu ve yaralanmanýn þüpheli kaldýðý olgularda rutin araþtýrýcý laparotomi tatbiki yüksek negatif laparotomi ile birliktedir. Bu hastalarda laparotomi öncesi invaziv ve noninvaziv testler ve görüntüleme yöntemleri uygulanmakla negatif oranýnda önemli bir azalma olmuþtur. Buna karþýlýk bu testlerin yaratabileceði güven ortamý, gözden kaçabilecek yaralanmalar nedeni ile, morbidite ve mortalitede artýþa yol açabilir. Dolayýsýyla kunt ve penetran yaralanmalarda laparotomi uygulamak gibi konservatif kalmak da bir risk taþýmaktadýr. Bu nedenle biz Taksim Hastanesi I. Cerrahi Kliniði'nde erken morbidite ve mortalite açýsýndan, 358 künt ve penetran travmalý olgu içinden, 53 negatif laparotomi uygulanan hastayý 2-33 aylýk süre içinde takip ettik. 31 'i penetran, 22 'si künt travmaya karþý kalan hastalarýn 22 (%38) 'sinde ilave sistem ve organ yaralanmasý mevcuttu. Hastalar saf abdominal yaralanmak ve abdomen dýþý yaralanma da mevcut olanlar olmak üzere iki gruba ayrýldý. Gruplar atelektazi, pnömoni ve intestinal obstrüksiyon (majör), flebitis ve yara infeksiyonu (minör) gibi komplikasyonlar geliþimi yönünden kýyaslandý. Sonuçlar Fisherin exact t testi ile deðerlendirildi. Penetran yaralanmalarda lokal eksplorasyon ve peritoneal lavaj, künt travmalarda, peritoneal lavaj ve bilgisayarlý tomografinin uygulanmasý ile negatif laparotomi sayýlarýnda önemli bir azalma olmuþtur. Fakat intraabdominal organ yaralanmasý bulgularý olan yaralanmalarda, özellikle künt travmalarda batýn içi yaralanmanýn ekarte edilmesinin en kolay ve hýzlý yöntemi araþtýrýcý laparotomidir. Bu olayýn morbiditesi ölçülebilir ve minimaldir.

It is still an issue of debate that just how much the rate of negative laparotomy should be in cases of blunt and penetrating abdominal injuries. The rate of explorative laparotomy with negative findings is especially high in patients with minimal symptoms and signs where the existence of an actual organic injury is doubt. Recently, routine preoperative invasive and non-invasive tests and application of various techniques of intraabdominal visualization have caused a significant drop in the rate of negative laparotomy. But this may create a false feeling of security and may cause a rise in the morbidity and mortality through neglection. Being conservative may be hazardous in some as being invasive yet in another. Therefore at the Surgery Clinic of Taksim Hospital out of a pool of 358 patients with blunt and penetrating abdominal injuries we followed the occurrence of early morbidity and mortality in a total of 53 patients with negative laparotomy. 31 patients had blunt and 22 penetrating trauma. 22 patients (%38) had additional systematic and organic injuries. Patients were divided in two groups: one with pure abdominal and another with abdominal and extraabdominal injuries. Both groups were compared in relation to the occurence of major complications such as atelectasis, pneumonia and intestinal obstruction and minor ones such as phlebitis and wound infection. Results were analyzed with the Fisher's exact t test. The use of local exploration and peritoneal lavage in penetrating and peritoneal lavage and computed tomography in blunt injuries have caused a dramatic decrease in the rate of negative laparotomy. But in patients with especially blunt trauma who poses some signs of intraabdominal injury the easiest and the most quick method of evaluation is explorative laparotomy. The morbidity of this procedure is measurable and minimal.

1989-1992 yýllarý arasýnda 25 adet açýk kýrýðý tedavi edildi. Hastalarýn yaþ ortalamasý 10 (3-15 olup, ortalama izleme süresi 1 yýl (6ay-2 yýl) idi. Olgularýmýzýn 13'ü (%57) erkek, 10'u (%43) kýz çocuðu idi. Olgularýn %60,9'unda açýk kýrýklarýn nedeni trafik kazasý olup, %43.3'ünde birlikte diðer yaralanmalar vardý. Gustilo'nun sýnýflamasýna göre kýrýklarýn 4'ü (%16) tip I, 5'i (%20) tip II, 16'sý (%64) tip III açýk kýrýklar olup 17'si (%68) alt, 8'i (%32) üst ekstremiteye ait idi. Tip III C açýk kýrýðý olan ve ilk tedavi olarak amputasyon uygulanan hasta dýþýndakilere debridman, irrigasyon, açýk redüksiyon ve internal tesbit uygulandý. Tüm olgulara ilk deðerlendirmelerinden sonra koruyucu intravenöz antibiotik uygulanmasýna baþlandý. Ondört (%60.9) hastaya yumuþak doku onarýmý için tekrar ameliyat yapýldý. Komplikasyon olarak; 1 (%4.3) ölüm, 1 (%4.3) akut böbrek yetmezliði, 3 (%13) yumuþak doku enfeksiyonu ve 4 (%17) olguda eklem hareket kýsýtlýðý saptandý. Olgularýn hiçbirisinde ostemiyelit, kaynamama, kaynama gecikmesi, kötü kaynama, eksremite uzunluk farký saptanmadý. Çocuk açýk kýrýklarýnýn cerrahi tedavisinde açýk redüksiyon ve internal tesbit yönteminin, dikkatli debridman ve irrigasyonla birlikte kullanýlmasý olgularýn erken dönem sonuçlarý üzerinde olumlu etkisi olmaktadýr.

Results of twenty five open fractures in twenty three patients between the years 1989-1996 were reviewed. The patients were between three and fifteen years old (mean age 10). Thirteen of the cases were male (57%), ten of them were female (43%). The average follow-up period was one year. Of 23 patients, 14 (60.9%) had been injured in motor vehicle accidents, and 43.3% per cent had associated injuries. Four (16%) fractures were graded as Grade I, five (20%) Grade II and sixteen (64%) Grade III open fractures according to the classification of Gustilo. Seventeen patients had lower extremity fractures and eight had upper extremity fractures. Twenty two patients were treated with immediate debridement, irrigation, open reduction and internal fixation and three (13%) Grade IIIC open fractures were treated with amputation. All patients received intravenous antibiotic treatment at the emergency room. Fourteen (60.9%) patients needed a second operation for soft tissue reconstruction. On follow-up, one (4.3%) patient died, one (4.3%) patient had acute renal failure, three (13%) had soft tissue infections and four (17%) had some restriction of range of joint motion. Open reduction and internal fixation with careful debridement and irrigation has positive effects on the early results in children with open fractures.

Delici göz yaralanmasýyla 1988-1991 tarihleri arasýnda Ýstanbul Týp Fakültesi Göz Hastalýklarý Kliniðine acil olarak baþvurmuþ hastalarýn muayene bulgularý, uygulanmýþ olan cerrahi giriþimler ve takip bulgularý deðerlendirildi. Ýlk muayene bulgularýndan daha sonraki görmeye etki edenler araþtýrýldý. Onaltý yaþ altýnda 246 olgunun 175'i erkek, 71'i kýzdý. Olgularýn %42.27 ile en fazla kesim 6-10 yaþ arasýndaydý. Olgularýn 203'ü 0.1'den daha az görmeyle baþvurmuþlardý. En sýk görülen yara yeri lokalizasyonu korneada idi. Ýlk muayene bulgularý ve yaralanmanýn özelliklerine göre takip sýrasýnda saptanan görme keskinliðine etki eden faktörler þöyle sýralanýyordu. Hifema p<0.001, lens yaralanmasý p<0.02, parçalý korneal keþi p<0.02,3 mm'den büyük korneal kesi p<0.04, ve sokakta olmuþ travma p<0.04.

Patients presenting with penetrating eye trauma at Dept. of Ophtalmology Istanbul Faculty of Medicine between 1988 and 1991 were evaluated, and examination findings, performed surgical interventions and follow-up findings were investigated. Initial findings affecting later visual outcome were assessed. 246 cases were under 16 years; 175 were male and 71 were female. The majority of cases (42.27%) were between 6 and 10 years. 203 cases had an initial vision of 0.1 or less. The most common site of injury was the cornea. Initial examination findings and factors affecting vision noted during follow-up according to injury characteristic were: Hyphema (p<0.001), lens injury (p<0.02), lacerated corneal injury (p<0.02) (only corneal injuries), corneal laceration greater than 3mm (p<0.04) (only corneal injuries), street injuries (p<0.04).

Bu çalýþma Ýstanbul Týp Fakültesi Acil Dahiliye Servisine son 5 yýl içinde baþvuran, üst gastrointestinal sistem kanamasý (ÜGK) bulunan 595 vakada klinik seyir üzerinde etkili olan faktörleri belirleme ve ÜGK geçiren vakalara yaklaþýmý deðerlendirme amacýyla yapýlmýþtýr. Ýncelenen hastalarýn 413'ü (%69.4) erkek, 182'si (%30.6) kadýndýr. Klinik seyir üzerinde etkili faktörler olarak, hasta yaþýnýn 50'nin üzerinde olmasý, hematemez ile baþvurmasý, anamnezde geçirilmiþ ÜGK ya da peptik ülser hastalýðý bulunmasý ve pozitif Tüt testi ele alýnmýþtýr. Bu faktörlerin bulunduðu grup, bulunmayan gruba göre istatistiksel açýdan anlamlý düzeyde daha yüksek miktarda kan transfüzyonuna gereksinim göstermiþtir. Cerrahiye sevk bakýmýndan, daha önce ÜGK geçiren ve pozitif Tilt testi olan gruplarda olmayanlara göre istatistiksel açýdan anlamlý fark bulunmuþtur.

This study was conducted to analyse the association of risk factors and clinical course of upper gastrointestinal bleeding (UGB) and evaluate the approach to UGB. 595 cases (%64.9 males) of UGB admitted to medical emergency department of Istanbul University School of Medicine between 1991-1996 were assessed. Patient age over 50, hematemesis at admission, a history of UGB or peptic ulcer disease and a positive Tilt testing were considered to be important factors in the clinical course of UGB. The subgroup of patients with any risk factors required more units of blood transfusion than patients without risk factors. The subgroup of patients with only a positive Tilt test or a history of UGB required surgical intervention more frequently.

Toraks travmasý nedeniyle yatýrýlarak tedavi edilen 239 hastanýn 9'una minitrakeotomi uygulandý. Hastalar sigara içen erkek olgulardý. Yaþlarý 36-72 arasýnda ortalamasý 54 idi. Hastalarýn hepsinde multipl kot kýrýklarý ve akciðer kontüzyonu vardý. Minitrakeotomi lokal anestezi altýnda uygulandý. Ortalama kalýþ süresi 4.2 gün oldu (3-12). Bir hastada ses deðiþikliði dýþýnda komplikasyon görülmedi. Toraks travmasý sonrasý aðrýnýn neden olduðu balgam birikimi, atelektazi, pnömoni ve solunum yetmezliði gibi komplikasyonlar kolay uygulanabilen, düþük morbidite taþýyan minitrakeotomi ile önlenebilir.

Minitracheotomy was performed in 9 of 239 patients who were hospitalized for thoracic trauma. All were smoker males. Their ages were between 36-72 with an average age of 54. All had multiple rib fractures and pulmonary contusion. The procedure was performed under local anesthesia. Duration time was 3-12 days (average 4.2). No complications besides hoarseness in one patient occurred. The deadly consequences of thoracic trauma such as sputum retention, atelectasis, pneumonia and respiration failure due to pain can easily be prevented with minitracheotomy which can be easily performed with low morbidity rates.

Her türlü acil hastalýk ve travmada hayat kurtarýcý giriþimlerin yapýlabilmesi için tam teþekküllü acil servislere ihtiyaç vardýr. Ülkemizde ilk yardým ve transport hizmetlerine ve acil servislere yeteri kadar önem verilmemektedir. 1993 yýlýnda hizmete açýlan hastanemiz acil servis binasý, tüm branþlara ait acil baþvurulan ve giriþimleri ayný çatý altýnda toplamasý özelliði ile ülkemizde ilk örneklerden biridir. Reanimasyon odasý, poliklinikler, laboratuarlar, bilgisayarlý tomografi, ameliyathaneler, yoðun bakým servisi gibi birimleri bünyesinde barýndýrmaktadýr. Acil servise, 1994 yýlý içerisinde 107.768 (295.5 kiþi/gün) hasta acil olarak baþvurdu. 1891 (5.2 kiþi/gün) hastaya ameliyat yapýldý. 709 (1.9 kiþi/gün) hastaya yoðun bakým hizmeti verildi. Ülkemiz koþullarýna, hekimi, personeli ve malzemesi bir eðitim hastanesi tarafýndan karþýlanan çaðdaþ acil servislerin uygun olacaðýný düþünmekteyiz.

In order to perform life saving procedures for every case of acute disease and trauma, perfectly organized emergency clinics are required. In our country the importance of the first aid and ambulance transport services isn't considered sufficiently. Our emergency clinic, which was established in 1993, serves in all branches, both medical and surgical, so that all mind of acute intervention can be carried out under the same roof. With these features, it is one of the first examples in this area in Turkey. Our emergency clinic consists of reanimation ward, policlinics, laboratories, computerized tomography, theatre rooms and intensive care unit. In 1994, 107768 patients were admitted to our emergency clinic (mean 295.2 patients/day) and operations were performed for 1891 of them (mean 5.2 operations /day). 709 patients were kept under supervision in the intensive care unit for while (mean 1.9 patients /day). We think that contemporary emergency clinics-the staff and equipment of which are being supplied by educational hospitals-are appropriate for our country's conditions.

Bu çalýþmada 1996 Ocak-Nisan aylarý arasýnda Dicle Üniversitesi Týp Fakültesi, Ýlk ve Acil Yardým Anabilim Dalý'na baþvuran 97 travma geçirmiþ hasta deðerlendirildi. Revize edilmiþ travma skoru (RTS) ve yaralanma þiddeti skorunun (ISS) hastanýn yaþama olasýlýðýný belirlemedeki yeri karþýlaþtýrýldý. 72 hasta servise, 25 hasta yoðun bakýma yatýrýldý. Yoðun bakýma yatýrýlan 9 hasta öldü. Total mortalite %9 bulundu. ISS ortalama deðeri servisde yatan hastalarda 9.99±8.58, yoðun bakýmda yatan ve taburcu olan hastalarda 26.87±21.84 ve yoðun bakýmda ölen hastalarda 48.78±22.98 bulundu. RTS ortalama deðeri serviste yatan hastalarda 7.75±7.77, yoðun bakýmda yatan taburcu olan ve ölen hastalarda sýrasýyla 6.70±1.14 ve 2.86±2.53 olarak saptandý. RTS ve ISS yasayan hastalarý yasamayanlardan istatistiksel olarak anlamlý bir þekilde ayýrdý (RTS t=5.41 p<0.001, ISS t=4.56 p<0.001). RTS ve ISS'nin hastanýn yaþama olasýlýðýný istatistiki açýdan önemli bir þekilde belirlediðim tesbit ettik.

In this prospective study, 97 critically injured patients were evaluated at Dicle University Department of Emergency Surgery between January April 1996. The predictive power of injury severity score (ISS) and Revised trauma score (RTS) for the outcome of individual patients was studied. 72 patients were admitted to the hospital, 25 patients to the ICU. 9 patients died in the ICU, for a total mortality rate of 9%. The mean ISS was 9.99±8.58 in hospital survivors and it was 26.87±21.84 and 48.78± 22.98 in ICU survivors and non survivors respectively. The mean RTS was 7.75± 1.17 in hospital survivors, 6.70±1.14 in ICU survivors and 2.86±2.53 in ICU nonsurvivors. Both RTS and ISS separated survivors from nonsurvivors statistically (RTS t=5.41 p<0.001, ISS t=4.56 p<0.001.

Çalýþmamýzda Haziran 1994-Mayýs 1995 tarihleri arasýnda, künt ve penetran karýn travmasý nedeniyle Ýstanbul Týp Fakültesi Acil Cerrahi Ünitesine baþvuran 40 hastadan 15 tanesine invaziv taný yöntemi olarak sadece peritoneal lavaj (DPL), 15 tanesine sadece laparoskopi (DL), 10 tanesine ise önce DPL ardýndan DL yapýldý. DPL yapýlan 25 hastanýn 12 tanesinde (%48) laparotomi endikasyonu koydurtacak pozitif lavaj bulgularý saptandý. 13 tanesinde (%52) ise lavaj sonuçlarý negatif olarak deðerlendirildi. Lavaj sonucu pozitif olan hastalardan 11 tanesine (%44) terapötik laparotomi uygulandý, 1 tanesinde (%4) ise daha sonra yapýlan laparoskopiyle kanamasý durmuþ minör karaciðer yaralanmasý saptanarak laparotomiden vazgeçildi. Lavaj sonucu negatif bulunan vakalarýn 9 tanesinin (%36) sonraki takiplerinde de laparotomi gerekmedi. 4 tanesinde (%16) ise çeþitli sebeplerle laparotomi yapýldý. DL yapýlan 25 hastanýn 10 tanesinde (%40) laparotomi endikasyonu koydurtacak bulgular saptandý ve hepsine terapötik laparotomi uygulandý. 15 hastada ise laparotomi endikasyonu koydurtacak bulguya rastlanmadý. Bunlardan 1l tanesi (%4) kanamasý durmuþ minör karaciðer yaralanmasý idi. l hastanýn ise (%4) daha sonraki takibinde laparotomi gerekti ve retroperitoneal duodenum rüptürü saptandý. DPL yapýlan vakalarda hiç komplikasyon görülmezken, DL yapýlan diyafragma yaralanmak 2 (%8) hastada pnömotoraks geliþti.

In our study, among 40 patients who were admitted to the Emergency Surgery Unit of Istanbul Medical Faculty from June 1994 to May 1995, as an invasiv diagnostic procedure only peritoneal lavage (DPL) was performed for 15 patients and only laparoscopy (DL) was performed for 15 of them, but first DPL and subsequent DL were performed for the rest 10 patients. Among 25 DPL patients positive lavage result rates indicating laparotomy was found in 12 patients (48 %) and lavage results were considered as negative for 13 patients (52%). Eleven laparotomies were performed for lavage positive patients (44%). In one patient (4%) non-bleeding minor hepatic trauma was diagnosed by laparoscopy and laparotomy was cancelled. No laparotomy was necessary during the follow-up for 9 lavage negative patients (36%). Laparotomy was necessary for 4 of them (16%) for different purposes. In 10 DL patients (40%) laparotomy was indicated and laparotomy was performed for all of them. There were no findings requiring laparotomy among the rest 15. One of them (4%) was diagnosed with non-bleeding minor hepatic trauma. Retroperitoneal duodenal rupture was diagnosed by laparotomy in another patient (4%) later on. No complications were recorded among DPL patients while there were two pneumothorax cases among DL patients with diaphragmatic injury.

Uzun süreli profilaksi veya tedavi amacýyla oral antikoagulan kullanýmý kanama eðilimini artýrýr ve spontan kanamalara sebep olabilir. Spontan kanamalar sýklýkla hematemez, melena, epistaksis, meno-metroraji v.b. þeklinde görülmekle beraber nadiren karýn içi boþluða kanama þeklinde de karþýmýza çýkabilir. Bu tür bir kanama akut karýn tablosu oluþturarak yanýltýcý olabilir. Bu yazýda, oral antikoagulan kullanýma baðlý karýn içi serbest kanama ve buna baðlý akut karýn tablosuyla acil servise baþvuran bir olgu, literatürde nadir rastlanmasý nedeniyle sunulmuþtur.

Long term oral use of anticoagulant at prophylactic doses increase the tendency towards bleeding and can cause spontaneous bleedings. Although spontaneous bleedings often occur as hematemesis, melena, epistaxis and menorrhagia, they can rarely manifest as intraabdominal bleedings. This kind of bleeding can be misleading since it can be diagnosed as an acute abdominal syndrome. A rare emergency case of acute abdominal syndrome due to intraabdominal free blood is presented.