Double jeopardy revisited: Clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

Introduction

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult. Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

Methods

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

Results

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18-40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80-90 mm Hg). Median base excess was −6.5 (quartile range −12 to −2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

Conclusion

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.     

脑穿刺损伤并局部注药大鼠模型的构建初探

目的建立脑穿刺损伤并局部注药大鼠模型,为进一步研究奠定基础。方法成熟的wistar雌性大鼠20只,按随机数字表法分为正常对照组和脑穿刺损伤组,每组10只。脑穿刺损伤组大鼠麻醉后,微型钻钻孔、将针刺入颅内,经顶叶皮层插入脑组织中4 mm,伤及皮层,刺入位置为中线旁开3 mm,额状缝前3 mm,留针2 min,并用X线侧位片和正位片检查刺入位置和深度后退出。正常对照组仅开颅,不致伤。Wistar大鼠脑穿刺后,消毒断头取大鼠皮层细胞原代培养,经纯化后星形细胞传代培养,取第3代星形胶质细胞进行GFPA的免疫组织化学检查鉴定细胞形态,观察脑穿刺损伤组与正常对照组星形胶质细胞的光密度OD值、数密度值。结果经原代及传代培养,获得大量几乎为单一种类细胞,其特点为胞体较大,形状不规则,胞质较丰富,细胞核圆形或卵圆形,常偏于胞体一侧,细胞突起较多较长,符合星形胶质细胞形态。免疫荧光检测显示GFAP阳性细胞为97%,脑穿刺损伤组原代培养细胞数量增多,脑穿刺损伤组与正常对照组星形胶质细胞的数密度分别为73.41±6.53和51.37±5.36,2组比较差异有统计学意义(P<0.05)。脑穿刺损伤组与正常对照组星形胶质细胞的光密度值分...     

带状疱疹中医与西医治疗的疗效观察

目的：比较隔蒜围灸加围刺治疗带状疱疹与常规药物治疗的疗效差异。方法：将322例患者随机分为治疗组（168例）和对照组（154例）,治疗组采用隔蒜围灸加围刺为主治疗的方法,对照组用常规药物治疗,观察止疱、止痛、后遗神经痛等方面的治疗效果。结果：治疗组总愈显率为95.9%,对照组愈显率为52.6%,两组比较差异有非常显著性意义（P<0.05）。结论：隔蒜围灸加围刺为主治疗带状疱疹,方法简便、安全,临床疗效显著。     

Testosterone decreases reactive astroglia and reactive microglia after brain injury in male rats: role of its metabolites, oestradiol and dihydrotestosterone

Previous studies have shown that the neuroprotective hormone, testosterone, administered immediately after neural injury, reduces reactive astrogliosis. In this study we have assessed the effect of early and late therapy with testosterone or its metabolites, oestradiol and dihydrotestosterone, on reactive astroglia and reactive microglia after a stab wound brain injury in orchidectomized Wistar rats. Animals received daily s.c. injections of testosterone, oestradiol or dihydrotestosterone on days 0-2 or on days 5-7 after injury. The number of vimentin immunoreactive astrocytes and the volume fraction of major histocompatibility complex-II (MHC-II) immunoreactive microglia were estimated in the hippocampus in the lateral border of the wound. Both early and delayed administration of testosterone or oestradiol, but not dihydrotestosterone, resulted in a significant decrease in the number of vimentin-immunoreactive astrocytes. The volume fraction of MHC-II immunoreactive microglia was significantly decreased in the animals that received testosterone or oestradiol in both early and delayed treatments and in animals that received early dihydrotestosterone administration. Thus, both early and delayed administration of testosterone reduces reactive astroglia and reactive microglia and these effects may be at least in part mediated by oestradiol, while dihydrotestosterone may mediate part of the early effects of testosterone on reactive microglia. In conclusion, testosterone controls reactive gliosis and its metabolites, oestradiol and dihydrotestosterone, may be involved in this hormonal effect. The regulation of gliosis may be part of the neuroprotective mechanism of testosterone.     

针灸联合刺络拔罐治疗带状疱疹的临床疗效观察

[目的]观察针灸治疗结合刺络拔罐治疗带状疱疹的临床疗效。[方法]将90例带状疱疹患者按随机数字表法分为A组、B组、对照组,每组患者各30例,A组采用针灸常规治疗联合刺络拔罐,B组采用针灸常规治疗,对照组采用口服盐酸伐昔洛韦与甲钴胺片治疗,疗程为10d。疗程结束后比较3组的总有效率及VAS评分与带状疱疹症状积分。[结果]A组、B组、对照组总有效率分别为93.33%、86.67%、76.67%,A组与对照组比较差异有统计学意义（P〈0.05）。VAS评分与带状疱疹症状积分比较结果均显示：A组、B组分别与对照组比较差异均有统计学或显著统计学意义（P〈0.05,P〈0.01）,A组与B组比较差异无统计学意义（P〉0.05）。[结论]针灸结合刺络拔罐治疗带状疱疹能较好地促进疱疹消退和缓解患者疼痛,其疗效优于口服盐酸伐昔洛韦与甲钴胺片,但与单纯采用针灸常规治疗组相比疗效不具有显著性差异。     

Obscure traumatic cardiac lesion after a penetrating chest injury: Review of the literature

We report a young man who sustained a penetrating chest injury after an assault. He was immediately transferred from a regional hospital to Queen Mary Hospital for definitive treatment after initial stabilization. Emergent thoracotomy was done in the operating theatre and primary repair of a cardiac laceration was performed. Postoperative transoesophageal echocardiography showed a large residual ventricular septal laceration with significant left to right intracardiac shunting. He had an open repair in a cardiac surgery centre the next day. A 1.5 cm laceration was found at the ventricular septum and repair was performed. Postoperative transoesophageal echocardiography showed no further ventricular septal defect. He underwent uneventful recovery and was discharged on day 6 postoperation. Follow up at 1 month postoperation did not show any abnormalities and he subsequently defaulted further follow up.     

Apoptosis after Injuries in the Cerebellum of Adult Teleost Fish

In contrast to mammals, all teleost fish examined thus far exhibit an enormous potential to regenerate not only neuronal processes (axonal regeneration), but even whole neurons (neuronal regeneration) after injuries in the central nervous system. By application of lesions to one subdivision of the cerebellum, the corpus cerebelli, the role of apoptosis in neuronal regeneration was examined in the gymnotiform fish,Apteronotus leptorhynchus.Apoptotic cells were identified by examination of cryosections with the terminal deoxynucleotidyl transferase-mediated dUTP–biotin nick end labelling (TUNEL) reaction, anin situtechnique employed for detection of nuclear DNA fragmentation. Additional evidence for the apoptotic nature of dying cells was obtained through analysis of morphologies displayed at both the light microscopic and the ultrastructural level. The first TUNEL-positive cells at the site of the lesion appeared as rapidly as 5 min following mechanical damage of the tissue. Thirty minutes after stab wound lesion, their number reached maximum levels. Starting with 2 days of postlesioning survival time, a gradual decline in the number of TUNEL-positive cells was evident, until this process reached background levels 20 days after the lesion. We hypothesize that apoptosis is used inA. leptorhynchusas an efficient mechanism for the removal of cells damaged through injury in the central nervous system. Since apoptosis is not accompanied by the side-effects known from necrosis (which is predominant after injuries in the mammalian central nervous system), this “clean” type of cell death may, at least partially, explain the tremendous regenerative capability of teleosts.     

变异型刺创致伤工具的推断方法

目的为了探讨推断变异型刺创伤的形成工具。方法通过对516例他杀案的有关资料进行分析。结果发现用刺杀人为96例（18．6％），现场工具单刃59例（61．5％），锐器33例（34．4％），钝器为4例（4．16％）；其中发生变异型刺伤16例（16．7％）；结论变异型刺创伤是刺于口形状与刺器横断面形状之间出现差异。辅助检查为衣服检验；伤口周围和创底检验等；推断变异刺伤的现场工具应根据皮肤、骨质、内脏、衣服创口的形态综合分析判断。     

脊髓锐器伤的临床疗效及预后观察

目的探讨脊髓锐器伤的临床特点、治疗方案及脊髓功能的预后规律。方法定期随访、回顾性分析我科2003年4月～2006年6月收治的8例脊髓锐器伤的治疗、预后转归情况。8例中男性7例,女性1例;年龄10～32岁,平均21.4岁。均为不完全性脊髓损伤。入院后经甲泼尼龙、神经节苷脂、高压氧及脱水综合治疗,术前和术后进行神经功能评分和影像学观察。结果经过平均5.4个月治疗后,所有患者下肢感觉、运动功能恢复满意,生活完全自理。平均随访17个月,其中4例下肢感觉恢复正常,4例残留部分感觉障碍;5例运动完全正常,3例遗有部分运动功能障碍,轻度跛行。结论脊髓锐器伤多为不完全性脊髓横断伤,局部创伤小、出血少、离断的神经组织无明显移位、纤维瘢痕组织增生少,脊髓功能恢复好;脊髓功能的恢复在伤后3周左右达高峰;药物促进离断后无明显移位的轴突原位修复、残留神经纤维的代偿可能是脊髓锐器伤后脊髓神经功能恢复的主要机制。     

CT引导下经皮纤维环穿刺建立兔腰椎间盘退变模型

【摘要】 目的：在CT引导下经皮纤维环穿刺建立兔腰椎间盘退变模型,并通过影像学和病理学验证其退变过程及效果。方法：3月龄新西兰大白兔18只,体重2.7~3.3kg,雌雄不限,术前均行X线及MRI检查。每只兔在螺旋CT引导下,用18G穿刺针经侧方皮下穿刺兔L5/6椎间盘（穿刺组）,确认刺入椎间盘纤维环深度约为5mm,并对L4/5椎间盘进行假性穿刺（穿刺达椎间盘边缘,但不刺入纤维环内;假穿刺组）,L3/4椎间盘作为对照椎间盘（对照组）。术后4周、8周、12周随机选取6只兔行X线片及MRI检查,观察各组椎间隙高度、邻近骨质改变及椎间盘信号改变,以“术后椎间隙高度/术前椎间隙高度×100”计算椎间盘高度相对值(DHRV),并进行椎间盘改良Thompson分级法分级;X线片及MRI检查结束24h内处死动物,选取对照、假穿刺和穿刺组椎间盘进行组织形态学及免疫组织化学分析。结果：对照组及假穿刺组术后4、8、12周,X线片示椎间隙高度无降低,无终板骨质硬化与骨赘形成;MRI T2加权成像图像示各椎间盘均呈高信号;组织学检查见髓核细胞数量较多,分布均匀,纤维环排列呈同心圆层状;免疫组化分析髓核呈Ⅰ型胶原染色强阳性,Ⅱ型胶原染色阴性,在各时间点表现无明显差别。穿刺组椎间盘在术后4周X线片即可见椎间隙高度轻度降低（DHRV=70.78±4.55）,MRI示椎间盘信号强度轻度下降,组织学上见纤维环结构紊乱、髓核细胞轻度减少;术后8周椎间隙高度明显降低（DHRV=50.63±4.04）,开始出现终板骨质硬化,MRI示椎间盘信号强度明显下降,组织学上髓核被胶原组织分裂为含较多椭圆形细胞的细胞岛,出现纤维软骨细胞,纤维环层状结构变形、部分断裂;术后12周椎间隙高度继续下降（DHRV=44.78±2.61）,骨赘形成、终板骨质硬化明显,MRI示椎间盘信号强度继续减弱,组织学上见髓核被纤维软骨组织所代替,纤维环层状组织碎裂、解体;免疫组织化学分析示术后4、8、12周髓核Ⅰ型胶原染色逐渐增强,Ⅱ型胶原染色逐渐减弱。各时间点对照组椎间盘的DHRV及改良Thompson分级与假穿刺组比较均无统计学差异（P＞0.05）;穿刺组在术后不同时间点的DHRV降低、改良Thompson分级增高与对照组及假穿刺组比较均有统计学差异（P<0.05）;随着穿刺时间的延长,穿刺组DHRV呈进行性降低趋势,改良Thompson分级进行性升高,两者在术后4、8、12周间均有统计学差异（P<0.05）。结论：CT引导下经皮纤维环穿刺法诱导兔椎间盘退变模型构建成功,操作方法简单、创伤小,经影像学及病理学证实其退变过程为渐进性。