Iatrogenic extrapleural hematoma

We encountered a rare case of complications at the time of central venous catheterization due to extrapleural hematoma. A 71-year-old woman was scheduled to undergo subtotal gastrectomy. After introduction of general anesthesia, a CVP catheter was inserted from the right jugular vein, but it was removed intraoperatively, because of poor dropping of the infusion fluid. A few minutes later, the blood pressure started to decrease. We considered that this symptom was derived from the surgical procedure, and rapid blood transfusion associated with administration of a vasopressor was performed. Postoperative chest X ray revealed poorly delineated right lung field, and hemothorax was suspected. However thoracic drainage resulted in an extremely small amount of blood-like fluid. The abnormal defect in the right pulmonary field was found to be an extrapleural hematoma by thoracic CT on the first postoperative day. The hematoma was reduced by subsequent management in 7 days, and the patient was discharged from the ICU without any further complications.     

Rapidly expanding extrapleural hematoma

We present a rare case of extrapleural hematoma due to chest trauma in an anticoagulated male patient. Chest computed tomography revealed multiple left rib fractures and a D-shaped opacity in the upper left side of the thorax suggesting extrapleural hematoma, which was caused from continuous bleeding. His past history included alcoholic liver cirrhosis, which caused thrombocytopenia and coagulopathy. Therefore, the hematoma was expanding, causing circulatory and ventilatory disturbance and severe anemia despite the difficulty of expanding in the extrapleural space. As the bleeding did not stop, even after intercostal artery angiography with embolization was performed, surgical treatment was undertaken to control the bleeding and evacuate the huge hematoma. The problems associated with the diagnosis and treatment of an extrapleural hematoma are discussed in the light of this case.     

Huge extrapleural hematoma in an anticoagulated patient

We report an unusual case of huge extrapleural hematoma in an anticoagulated patient with no apparent traumatic episode. An extrapleural hematoma (EH) was successfully treated by video-assisted thoracic surgery (VATS). If an EH is large enough to cause ventilatory or circulatory disturbances, VATS may be the first option for the management of EH. Otherwise limited thoracotomy should be considered.     

Removal of the intrapleural hematoma after extrapleural pneumonectomy

Three cases of pleuropneumonectomy, which have been performed in our institution between 1996 and 2003, are studied. All of them received re-thoracotomy to remove intrapleural hematoma for prolonged high fever, anemia and high level of CRP. Post re-operative courses were satisfactory without any signs of infection. The residual intrapleural hematoma sometimes causes pyothorax and would be an obstacle to the intrapleural instillation of anticancer medications. The removal of the hematoma should be scheduled at an early period after the pleuropneumonectomy.     

Nomenclature and classification in orthopaedics

In the following report we give a definition of the terms nomenclature and classification. We find out, that the two terms are very similar. They include the keys for diagnosis and therapy. We propose a method to construct new coding-systems. Furthermore we report about the existing coding-systems in Orthopaedics and Traumatology. We cite a list of national and international coding-systems. Because of the actuality we finally give a definition of the term "Indikationsspezifische Komplikation", which is of importance since the "5. Anderungsverordnung" of the "BPFLV-95" within the classification of the "Fallpauschalen". "Fallpauschalen" are a system like the American DRG's (Diagnosis related groups), but not exactly the same.     

Delayed traumatic intracerebellar hematoma

A case of delayed traumatic intracerebellar hematoma is presented in which the patient survived after diagnosis and surgical intervention. The computed tomographic and clinical features of this entity are reported, and theories of pathogenesis are discussed. We advise a high index of suspicion for delayed intracerebellar hematomas in patients with cerebellar contusion following trauma.     

Post traumatic intracerebellar hematoma

Summary Traumatic intraparenchymal hematoma of the cerebellum is a rare and dangerous entity which requires prompt diagnosis. The authors report a case of subacute cerebellar hematoma, diagnosed by CT scan examination and treated successfully by removal of the blood clot.

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Zusammenfassung Eine traumatische intraparenchymale Blutung in das Kleinhirn ist eine seltene, aber gefährliche Krank-heitseinheit, die sofortige diagnostische Maßnahmen erfordert. Die Autoren berichten hier über einen Fall eines subakuten cerebellären Hämatoms, das durch Computer-Tomographie diagnostiziert wurde und danach durch Entfernung des Blutkoagulums erfolgreich behandelt werden konnte.

     

Management of traumatic retroperitoneal hematoma

Traumatic retroperitoneal hematoma (RPH) may arise from injury to bony structures, major blood vessels, and intestinal or retroperitoneal viscera. To categorize the management of RPH, the retroperitoneum may be divided into three zones. Zone 1 (central) extends from the esophageal hiatus to the sacral promontory. Zone 2 (lateral) extends from the lateral diaphragm to the iliac crest. Zone 3 (pelvic) is confined to the retroperitoneal space of the pelvic bowl. For the traumatized patient with RPH, laparotomy is mandated by persistent hemodynamic instability despite intensive volume replacement. The judgment of whether and when to explore the retroperitoneal hematoma is guided by the mechanism of injury (blunt or penetrating) and the location of the RPH. RPH localized to the upper central area (Zone 1) after penetrating trauma implies injury to the great vessels and always requires urgent surgical exploration. RPH in other zones should be evaluated by CT and/or angiography; ongoing hemorrhage may respond to therapeutic embolization.     

创伤性腹膜后血肿的诊断和治疗

目的 探讨创伤性腹膜后血肿的早期诊断及合理治疗方法。方法 回顾性分析近10年收治的创伤性腹膜后血96例的临床资料。结果 82例手术治疗，其中73例合并腹腔脏器损伤；14例非手术治疗。2例合并颅脑损伤及1例失血性休克术中死亡，2例术后死于多器官衰竭。结论 早期诊断主要依靠临床表现，腹穿，B超和CT。钝性伤后表现有明显失血性休克，证实有腹腔内脏器或血管损伤，以及穿途伤后所致腹膜后血肿均应及时手术；肾周血肿或仅为骨盆区血肿则无需立即手术。     

Delayed traumatic intracerebral hematoma.

Although delayed traumatic intracerebral hematomas (DTICHs) have been frequently reported since 1970, the time interval from trauma to hemorrhage and diagnosis has not been well defined. Eight patients with DITCH were found among 1,320 head-injured patients admitted to the neurosurgical service through the emergency department from March 1989 to March 1990. The mean time interval between initial and follow-up CT scan was 22 h. The mean time interval between initial trauma and diagnosis of DITCH was 24 h. One patient was diagnosed incidentally by magnetic resonance imaging. Three patients underwent operation and five patients were managed conservatively. Three patients died, resulting in a case mortality rate of 37.5%. The time interval for DTICHs' development and pitfalls in its diagnosis were discussed.     

外伤性颅内血肿手术后并发迟发性血肿分析

目的分析外伤性颅内血肿手术后并发迟发性颅内血肿,探讨其与诸多因素的关系。方法回顾性调查1994年1月至2002年12月期,间本院收住的764例外伤性颅内血肿手术病人熏术后并发迟发性颅内血肿共98例,对其年龄、受伤机制、血肿厚度与中线移位的关系、血肿量、血肿部位、脑挫裂伤、手术时机以及术后骨窗的压力与发生迟发性血肿的关系,进行研究分析。结果诸多因素与并发迟发性血肿之间的存在相关关系。结论迟发性颅内血肿是颅脑外伤手术后较常见和严重的并发症,对其的发生应有足够的预见性,早期诊治是降低其死亡率和致残率的关键。     

Conservative treatment of traumatic intracerebral hematoma

In the previous report, it was insisted that traumatic intracerebral hematoma should be regarded as a variety of cerebral confusion and that conservative treatment would be therapy of choice in these situations. Adversely, unjudicious operation would sometimes result in more expansion of hematoma by untamponade effect of decompressive craniectomy. In the present investigation, it was attempted to provide therapeutic policy in the management of traumatic intracerebral hematoma. Consecutive thirty two cases of traumatic intracerebral hematomas were selected for this study. Those cases with other hematoma such as epidural or subdural hematoma were excluded. These 32 cases were divided into two groups, operative (15 cases) and non-operative (17 cases). Whether to be operated or not was arbitrarily decided by the surgeons who were faced to the patients. Disturbance of consciousness of the patients were divided into three categories, namely severe (III-100 to 200 level), moderate (II-10 to 30 level), and mild (I-1 to 3 level). They were 8 cases, 5 cases, 1 case in operative cases and 6 cases, 10 cases, 1 case in non-operative cases respectively. Mortality rates were 13.3% (2 cases) in operative cases and none in non-operative ones. Concerning the patients of severely disturbed consciousness, there were no difference in their final outcomes between the two groups. On the other hand, 7 out of 10 cases of moderately disturbed consciousness recovered completely without operation, whereas all operative cases of the same category were, more or less, handicapped.     

Neurosurgical treatment of traumatic intracerebral hematoma

From January 1st to August 31st 2002 yr., Neurosurgical department of the Trauma Center, Clinical Center of Serbia, has operated 43 patients with posttraumatic intracerebral haemathoma (PTIH). From that number, 9 patients survived and 34 died. Only 4 patients with acute PTIH were in terminal state of incarceration and in spite they were operated immediately, all died. Other 39 patients have delayed PTIH where secondary CT cerebral scans showed the development of posttraumatic intracerebral haematoma that has not been verified at the incipient scanner. Indication for repeated CT scan was found for 19 patients for their focal or general neurological deterioration. 20 patients had no delayed neurological disturbances. Survivors were younger, in lower grade of coma and were mostly with temporal localisation of haemathoma.