Blunt Traumatic Aortic Injury

Background: Blunt traumatic aortic injury (TAI) is clinically difficult to diagnose, as signs and symptoms are unreliable and variable. The identification of TAI may be obscured by other injuries that are more apparent. Furthermore, radiologic evaluation of the mediastinum for this injury is not well defined. Most patients with TAI die immediately. Survivors have a contained rupture which requires crucial early diagnosis and treatment. Material and Methods: A Medline search was conducted using the terms "traumatic aortic injury", "aortic injury", "aortic trauma", and "thoracic trauma" from 1966 until December 2002. Investigations used in the diagnostic evaluation of blunt TAI were reviewed and an initial investigative approach to this condition formulated. Results: The choice of investigation for TAI depends on clinical suspicion, hemodynamic stability, availability, and rapidity of access to tests. These include chest radiography, helical computed tomography angiography (CT-A), transesophageal echocardiography (TEE), aortography, and intraarterial digital subtraction angiography (IA-DSA). CT-A is considered an excellent test in hemodynamically stable blunt thoracic trauma patients. TEE is preferred in unstable patients. Conclusion: Investigations must confirm or exclude TAI with great precision. CT-A is a reliable screening and now primary diagnostic test in the hemodynamically stable patient. A negative CT-A excludes aortic injury, with a positive or equivocal CT-A leading to treatment or further diagnostic evaluation. TEE is appropriate for the hemodynamically unstable patient but is operatordependent and not widely available. Aortography is still considered the reference test for blunt TAI and is used when the results from other modalities are inconclusive.     

Progress in the treatment of thoracic aortic aneurysms

Progress in the management of thoracic aortic aneurysm includes the following aspects:

1. the concepts of the disease itself, which is frequently generalized so that the second most common cause of late death is rupture of another aneurysm;
2. the diagnostic techniques used: computed tomographic scanning as well as aortography;
3. the medical treatment: with beta blockade and antihypertensive drugs in stable aortic injury in the patient with multiple critical injuries;
4. that hypothermic circulatory arrest with cardiopulmonary bypass and brain temperatures down to 16–20°C has increased successful aortic arch replacement from 50–75% to over 90%;
5. that rapid autologous transfusion by means of a modified Hemonetics machine can collect and process a unit of shed blood in 2–3 minutes and has reduced transfusion requirements by more than half;
6. the vigorous treatment of both consumptive and dilutional coagulopathies;
7. the new reconstructive techniques: involving composite valve graft replacement of the aortic valve, root, and arch as well as coronary artery reattachment;
8. that the use of viable tissue flaps in the treatment of infected aortic grafts as well as intravenous and local irrigation with antibiotics was successful in 8 of 9 of our cases;
9. that graft replacement with intensive antibiotic therapy was effective in 19 of 22 of our patients with mycotic thoracic aortic aneurysm.

     

Autosomal Dominant Polycystic Kidney Disease,incidental finding with trauma: Case report and review of the literature

Introduction

Pre-existing renal lesions predispose kidneys to effects of otherwise insignificant blunt trauma, and may uncommonly present as an incidental finding in the workup of a suspected renal injury.

Verletzungen der thorakalen Aorta

Objective. To study the role of endovascular treatment of acute aortic transection following blunt chest trauma. Methods. In the period between March 1999 and March 2002, 15 polytraumatized patients (13 males,2 females) were treated with endovascular stent-graft placement for acute aortic transection.The mean age of the patients was 34 years (range 13–75 years). The feasibility and success of the procedures were assessed by preoperative and postoperative CT scans.Implantations were performed under general anesthesia.Vascular access was via the right common femoral artery. Results. The primary, technical success rate was 87% (13/15) and the secondary technical success rate after 5 days was 100%.In two cases, incomplete sealing of the rupture site occurred. In the first case spontaneous sealing occurred after 5 days; the second case was successfully treated by the placement of an additional proximal cuff.Two patients died postoperatively due to polytrauma unrelated to the endovascular procedures. In another case, a dissection of the external iliac artery, which occurred at the end of the procedure,was treated by conventional graft insertion.No neurological complications occurred. Conclusion. Endovascular treatment of acute aortic transection is feasible.This technique seems to be a valuable option in comparison to the open procedure because of the lower rate of complications.     

Role of cervical spine radiography in the initial evaluation of stable high-energy blunt trauma patients

Background

Detecting cervical spine injuries in trauma patients is essential because undetected injuries in the this area may result in severe neurological disability and probably quadriplegia. Thus, radiography of the cervical spine is considered mandatory in the initial evaluation of trauma patients according to Advanced Trauma Life Support. This approach results in many unnecessary normal radiographs. Therefore, we performed this study to determine the role of routine cervical radiography in the initial evaluation of stable high-energy blunt trauma patients.

Methods

This was a prospective cross-sectional study including all hemodynamically stable high-energy blunt trauma patients with negative cervical physical examinations referred to our trauma center during a 5-month period (May to September 2010). Cervical radiographs, computed tomography (CT) scanning and magnetic resonance imaging were performed and reviewed for abnormalities.

Results

During the study period, 1,679 high-energy blunt trauma patients were referred to our center, of which 400 were hemodynamically stable and had negative cervical physical examinations. Cervical radiographs were found to be normal in all patients.

Conclusion

Cross-table cervical spine radiographs can be limited to those high-energy blunt trauma patients who have a positive cervical physical examination or those in whom the physical examination is not revealing. These radiographs also have low value for detecting occult cervical spine fractures, and CT imaging is considered the modality of choice in these cases.     

Risk factors for splenectomy in children with blunt splenic trauma

Background/Purpose: Nonoperative management and splenic preservation have become standards of care for management of pediatric blunt splenic trauma. However, review of the Pennsylvania Trauma Outcome Study (PTOS) registry found that 15% of children with blunt splenic injury still underwent splenectomy. The authors sought to determine the factors that predisposed to splenectomy in this population. Methods: Between 1993 and 1997, 754 children, ages 0 to 16 years, who sustained blunt splenic trauma were entered in the PTOS database. These patients were stratified into groups according to the mode of management: nonoperative, splenorrhaphy, or splenectomy. Logistic regression was performed to determine factors associated with splenectomy. Results: Overall, 15.1% of patients underwent splenectomy, 7.4% underwent splenorrhaphy, and 77.5% were treated nonoperatively. Spleen injury grade, nonspleen abdominal injuries, Glasgow Coma Scale 3 to 8, and age 15 to 16 years were significant determinants of splenectomy by multivariate analysis. Children treated at pediatric trauma centers (PTC) underwent significantly fewer splenectomies. Conclusions: Injury grade, but not hemodynamic instability, was a significant independent determinant of splenectomy in children with blunt splenic trauma. Children treated at PTC are less likely to undergo splenectomy. Ongoing analysis of the management of blunt pediatric splenic injury and reduction of unnecessary splenectomies are needed to optimize care for injured children.     

Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography?

Purpose

Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury.

Methods

Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma.

Results

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient.

Conclusions

According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.     

Die kontinuierliche Herzminutenvolumenmessung als “hämodynamisches Online-Monitoring” bei polytraumatisierten Intensivpatienten: Technisch möglich – klinisch sinnvoll?

Purpose. Is the measurement of continuous cardiac output useful for the management of polytrauma patients? Methods. In a prospective non randomized study (ethic comission file 43/96) we evaluated the diagnostic and therapeutic impact of the CCO (continuous cardiac output measurement) for polytrauma patients on the ICU. The Baxter Vigilance System was used for measuring the continuous cardiac output. The CCO values were controlled once a day by the conventional “cold” thermodilution technique. Results. All values are given as mean±standard deviation. The Patients were scored on the first day for ISS (injury severity score) (47±17) and APACHE II (15±5). The CCO was used no later than 12 hours after the initial treatment in 20 polytrauma patients. As clinical outcome parameters were chosen: days on ventilation (23±23 days), days on the ICU (31±26 days) and mortality (20%). The treating ICU physicians were asked in a standardized questionnaire, whether or not there was an impact of the CCO measurement on their therapy. Seven different surgeons were working with the system. Conclusion. The unique opinion was that the CCO device had an impact on their decision making in the fluid and drug management of the study patients. Our first experience, however, suggests that this device may become an important improvement in the management of haemodynamics in the early trauma phases. Before a wide-spread application of this method on the ICU an evidence based prospective randomized trial should be performed.     

Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature

INTRODUCTION

Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient''s primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality.

PRESENTATION OF CASE

A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient''s TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting.

DISCUSSION

TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success.

CONCLUSION

The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.     

Akute perioperative Störungen der Nierenfunktion

The increasing life expectancy in industrial nations leads to an increase in the number of elderly and aged persons treated in hospital. Increasingly more complex operations are being carried out on this group of patients. Renal dysfunction in the preoperative situation increases morbidity and mortality. Acute kidney injury (AKI) is nearly always part of a multi-organ dysfunction syndrome in critically ill patients. The treatment strategy of the AKI should be oriented to the degree of organ dysfunction. However, the stage of organ dysfunction is mostly unknown so that the therapeutically exploitable interval is often missed. The same therapy is practically always used for all patients: administration of fluids and diuretics often under the premise of“the kidneys must be rinsed”. A unified classification of the continuation of kidney function disorders using the RIFLE criteria (risk, injury, failure, loss, endstage kidney disease) can assist recognition of early stages of kidney failure in order to react correspondingly with therapeutic measures and to critically question or optimize the use of conservative treatment strategies.     

Significance of Computed Tomography Finding of Intra-Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Background

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective

The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods

During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results

A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion

Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.     

Erste klinische Erfahrungen mit der transnasalen ösophagealen Echokardiographie

Currently undergoing a clinical trial a new miniaturized monoplane ultrasound probe potentially enhances the practicability of perioperative transesophageal echocardiography (TEE) without loss of echocardiographic quality. Methods: In the present prospective study, the nasally inserted miniaturized TEE probe was tested in 12 ventilated patients and compared with a conventional TEE probe. Echocardiographic quality was tested by two independent investigators by analyzing the percentage of the endocardium contour detection (<50%, 50–75%, 75–100%) in the left ventricular short- and long-axis views. Results: In 11 patients, more than 50% of endocardium were visualized continuously with both probes. Although the nasal TEE probe was inferior to conventional TEE in detecting lateral endocardium, automated endocardium detection compared well with both methods. Inter- and intraobserver variability in manual measurements of the left ventricular cross-sectional area was below 5% on average and differed non-significantly with regard to the method. In 2 patients, continuous monitoring was aggravated by repeated loss of contact between the miniaturized TEE probe and mucosa. Conclusions: In comparison with conventional TEE, the miniaturized TEE probe provides practicability advantages without significant loss of information for cardiovascular monitoring.     

Liver injury following blunt abdominal trauma: a new mechanism-driven classification

Purposes

The current classifications for blunt liver trauma focus only on the extent of liver injury. However, these scores are independent from the localization of liver injury and mechanism of trauma.

Methods

The type of liver injury after blunt abdominal trauma was newly classified as type A when it was along the falciform ligament with involvement of segments IVa/b, III, or II, and type B when there was involvement of segments V–VIII. With the use of a prospectively established database, the clinical, perioperative, and outcome data were analyzed regarding the trauma mechanism, as well as the radiological and intraoperative findings.

Results

In 64 patients, the type of liver injury following blunt abdominal trauma was clearly linked with the mechanism of trauma: type A injuries (n = 28) were associated with a frontal trauma, whereas type B injuries (n = 36) were found after complex trauma mechanisms. The demographic data, mortality, ICU stay, and hospital stay showed no significant differences between the two groups. Interestingly, all patients with type A ruptures required immediate surgical intervention, whereas six patients (16.7 %) with type B ruptures could be managed conservatively.

Conclusions

This new classification for blunt traumatic hepatic injury is based on the localization of parenchymal disruption and correlates with the mechanism of trauma. The type of liver injury correlated with the necessity for surgical therapy.     

Europäischer Trainingskurs zur erweiterterten prähospitalen Traumaversorgung.

Goal. Course to improve the potential and abilities of the trauma team for prehospital management of trauma patients on site, during transportation, and primary care in the shock treatment room or emergency room. Target groups. Anesthesiologists,emergency physicians, trauma surgeons, ICU physicians, emergency medical technicians,and nursing staff in ER and ICU. Design. Theoretical course including practical exercises with phantoms and simulators.     

Surgical therapy of traumatic shoulder dislocation. Are there evidence-based indications for arthroscopic Bankart operation?

Introduction. For young athletic patients with a primary traumatic shoulder dislocation a surgical treatment is recommended. The operation of choice is the Bankart-Repair. Question. Are there evidence-based indications for an arthroscopic Bankart repair. Methods. Based on the criteria of the “Cochrane Collaboration” a systematic literature search was performed using medline (1966 to 9/2000). 172 publications were found with the key words “shoulder dislocation” and “Bankart”. All relevant articles were ranked and analysed by the criteria of “evidence-based medicine”. Results. There are 12 prospective studies (evidence grade Ib/IIa) and another 28 retrospective studies (evidence grade III). For open Bankart-Repair a recurrence rate of 0 to 8% is reported (prospective/retrospective studies). For arthroscopic Bankart-Repair, 19 of 40 studies and 8 of 12 prospective studies, show a recurrence rate of <10%; however in other studies (prospective/retrospective) an atraumatic recurrence rate of up to 38% is reported. The reasons for these differences in the recurrence rate are not obvious from the given data. In particular, there seems to be no correlation between the type of arthroscopic fixation technique and the recurrence rate. Concerning the postoperative range of shoulder motion, the reported data suggest that external rotation is less limited after arthroscopic than after open Bankart-Repair (arthroscopic: 5–12°, open: 5–25°). However, there is no evidence that patients are more likely to return to their previous level of sporting activities when operated on in an arthroscopic technique than in an open technique (arthroscopic: 42–100%, open: 72–94%). Conclusion. In the surgical treatment of a traumatic shoulder dislocation, the open Bankart-Repair remains the “gold standard”. In reviewing the literature, arthroscopic Bankart-Repair has not been shown to be equal or superior to the open technique.     

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

Background

Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.

Surgical management of traumatic rupture of aortic isthmus: a 25-year experience

Objective

Traumatic rupture of the thoracic aorta is a surgical emergency with a high mortality rate. This condition requires prompt diagnosis and expeditious evaluation to improve patient survival. The aim of this study is to evaluate the outcomes of early and late management of traumatic rupture of aortic isthmus in patients with blunt thoracic trauma.

Methods

Between February 1980 and June 2005, 64 patients sustained blunt thoracic trauma underwent open surgical repair for traumatic rupture of the aortic isthmus (7 women, 57 men, and mean age 38 ± 14.3 years). Clinical signs of diagnostic principles in our series of patients were: chest pain and dyspnea (48.5 %), hemoptysis (23.5 %), and hypotension (15.5 %). All patients underwent a left posterolateral thoracotomy through the fourth or fifth intercostal space or median sternotomy. Extracorporeal circulation for spinal cord protection was installed in all patients.

Results

Of the 64 patients identified over the 25-year study period, 15 (23.5 %) underwent direct suture, 48 (75 %) underwent interposition graft repair, and 1 (1.5 %) experienced patch aortoplasty repair. The overall hospital mortality rate for the entire patient was 3 % due to multiple organ failure and myocardial infarction. No paraplegia occurred postoperatively. Three patients died during the follow-up period, two from myocardial infarction, and one from acquired immunodeficiency syndrome.

Conclusions

Traumatic aortic rupture remains a potentially lethal injury and an ongoing therapeutic challenge. Open surgical technique to repair the traumatic rupture of aorta is a safe procedure: postoperative outcome was excellent and the complications observed that were with aortic endoprosthetic stent–grafts were avoided.     

Perioperative transesophageal echocardiography for non-cardiac surgery

Purpose

The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination.

Principal findings

Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, “rescue TEE” can be used to help identify the underlying cause.

Conclusions

Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.