Cervical vessel injury after blunt trauma

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.     

Gallbladder injuries resulting from blunt abdominal trauma: an experience and review.

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.     

Cardiac impalement from a rib after blunt trauma

Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically stable patient after blunt chest trauma with radiographic images suggestive of the left fifth rib penetration to the heart. The diagnosis, surgical approach, and course of the patient are discussed.     

Management of kidney injuries in children with blunt abdominal trauma

BACKGROUND/PURPOSE: The authors analyzed the incidence and the course of renal injuries encountered in a cohort of pediatric patients with blunt abdominal trauma. This review focuses on the early diagnostic and therapeutic approach rather than the long-term outcome and draws conclusions for an effective initial management. METHODS: From 1976 to 1996, the charts of 308 children with blunt abdominal trauma that were admitted to the authors' department were reviewed. The patients initially were evaluated using urinalysis, ultrasonography, and abdominal paracentesis (until 1984) and in specific cases iv-urography, computed tomography (CT), and angiography. The authors retrospectively classified the renal trauma after the widely used Organ Injury Scaling (OIS) into 5 grades and correlated the diagnostic value of various techniques as well as the diagnostic approach. RESULTS: Sixty-nine serious abdominal traumas were encountered. Thirty-six patients suffered renal lesions grade 2 (G2) or higher; 20 children were polytraumatized. There were 67 renal lesions including 28 G1, 22 G2, 8 G3, 5 G4, 1 G5, and 3 lesions of the lower urinary tract. Ultrasonography and urinalysis were found to be the optimal diagnostic methods for screening and following the course of renal injury. CT scan proved to be most reliable for detecting and exactly classifying renal lesions grade 2 or higher and superseded consecutively iv-urography. In cases in which CT scan failed to show renal excretion of contrast agent, angiography was performed. Ten patients proceeded to operative therapy. CONCLUSIONS: Ultrasonography and urinalysis proved to be the optimal initial evaluation tool for excluding renal injury both as a screening method and for further controls. Exact classification was possible by CT scan. During the reviewed time period a shift from surgical to conservative management was notable. If lesions were G4 or G5, surgical treatment with tendency toward minimally invasive therapy always was indicated.     

Pediatric cardiac and great vessel injuries: Recent experience at two pediatric trauma centers

Background: Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region.Methods: This is a retrospective review of pediatric (<18 years) patients who sustained cardiac or great vessel injuries and were managed at a Level 1 or Level 2 pediatric trauma center between January 1, 2010 and June 30, 2020. Demographic and clinical characteristics were compared using two-sample t-tests, Wilcoxon Rank-Sum tests, Fisher's exact tests and chi-squared tests for continuous, non-normally distributed continuous, and categorical variables, respectively.Results: A total of 53 patients sustained cardiac and/or great vessel injuries. Of these, 37 (70%) sustained cardiac, 9 (17%) sustained great vessel, and 7 (13%) sustained both types of injuries. The median age was 14.9 years and 74% (n = 39) were male. The median injury severity score (ISS) was 36.0 and the injury mechanism was blunt in 31 (58%) patients. The most common cardiac and great vessel injury locations were left ventricle (n = 9) and thoracic aorta (n = 11), respectively. The overall mortality rate was 53% (n = 28). Mortality was highest among those who sustained great vessel injuries (89%).Conclusions: There is substantial heterogeneity in cardiac and great vessel injuries. Regardless, they are highly morbid and lethal, despite aggressive surgical and catheter-based interventions.     

Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.     

Abdominal wall injuries occurring after blunt trauma: incidence and grading system

Background

Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury.

Methods

All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry.

Results

Of 1549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery.

Conclusions

AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.     

Airway management in laryngotracheal injuries from blunt neck trauma in children

Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Early diagnosis and skillful airway management is critical in avoiding significant morbidity and mortality associated with these cases. We present a case of a patient who suffered a complete tracheal transection and cervical spine fracture following a clothesline injury to the anterior neck. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children are presented.     

Adrenal injuries following blunt abdominal trauma in children: report of two cases

Adrenal injuries following blunt abdominal trauma are uncommon. Adrenal hemorrhage in children associated with multiple organ injury, which has received little attention in the past, is an increasingly recognized phenomenon in modern trauma centers with the widespread use of abdominal computed tomography. Adrenal trauma occurs in the setting of multisystem organ injury. Isolated adrenal injury is exceedingly rare. We report two children with blunt adrenal trauma (one isolated and one with associated injuries), who were admitted during the last two years to our Pediatric Surgery Department after abdominal trauma. We determined the prevalence, management and general prognosis of blunt adrenal injury in the pediatric population. Traumatic adrenal hemorrhage appears to be an incidental and unsuspected finding that resolves on follow-up imaging.     

Nonoperative management of liver injuries following blunt abdominal trauma in children

In a 4-year span, 12 patients with hepatic trauma were treated at our institution. After initial resuscitation, three underwent emergency celiotomy because of the severity of their injuries. This communication analyses the other nine. All of these had significant liver injuries and were managed nonoperatively. Hepatic injury was diagnosed and the severity defined by ultrasonography, radionuclide scintigraphy, or computed tomography (CT). These stable patients were initially admitted to the intensive care unit (ICU) and upon transfer to the ward, maintained on restricted activities. Seven of the nine children received blood transfusions. Although liver enzymes were initially elevated in each case, they returned to normal in 1 week. In-hospital and post-discharge imaging documented healing of the hepatic injuries in each case. Eight children are well at 3 months to 4 years follow-up. Only one of the nine nonoperatively managed patients died and this was secondary to severe head injuries. To date, there are no complications. Our nine children are added to the 23 nonoperatively treated pediatric hepatic injuries found in the literature.     

Injuries to the major airway after blunt thoracic trauma in children: review of 2 cases

Tracheobronchial injuries in children occur rarely. Their diagnosis is often very difficult and needs a high degree of suspicion, with in-depth knowledge of the anatomy of and radiological findings for the chest. With proper surgical management, even a delayed diagnosis can result in normal lung function. We discuss 2 cases of major airway injuries with successful outcomes and present some interesting surgical maneuvers.     

Papillary muscle rupture and pericardial injuries after blunt chest trauma.

Non-penetrating cardiac trauma resulting in mitral valve rupture is uncommon, requiring a high degree of suspicion for diagnosis. Sudden and severe mitral regurgitation, unless surgically corrected rapidly lead to congestive heart failure and death. We report a patient with traumatic rupture of the antero-lateral papillary muscle of the mitral valve and pericardial injury, after a lateral blunt chest trauma, who successfully underwent emergency mitral valve replacement.     

Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma

Introduction

Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT.

Methods

All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed.

Results

Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50).The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan.

Conclusion

Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.