A Case of Traumatic Aortic Transection Presenting With Hemorrhagic Shock

BackgroundAortic transection, or aortic rupture, is a rare diagnosis in trauma patients and carries a high mortality.Case ReportWe present the case of a 61-year-old man presenting to a Level I trauma center after being struck by a motor vehicle, found to have an aortic transection. He was initially hypotensive and resuscitated with blood products due to concern for hemorrhagic shock. Aortic injury was suspected after chest x-ray study demonstrated a widened mediastinum. Traumatic thoracic aortic transection with pseudoaneurysm was diagnosed on computed tomography of the aorta, and the patient was taken to the operating room for thoracic endovascular repair of the aorta.Why Should an Emergency Physician Be Aware of This?Diagnosis of aortic injury can be challenging, especially in trauma patients presenting with hypotension. Aortic injury must be suspected in patients presenting after a high-velocity mechanism injury. It is an uncommon cause of hemorrhagic shock in trauma patients and must be considered even if other traumatic injuries are identified, as it commonly occurs with other significant injuries. Although chest x-ray study can be useful, a negative chest x-ray study does not rule out aortic injury. Aortic injury is a time-sensitive diagnosis, and early identification is key to these patients surviving to receive definitive management in the operating room.     

Collaboration Between Interventional Neurosurgery and Vascular Surgery in the Hybrid Operating Room

With the development of hybrid operating room (OR) capabilities and rapid advances in neuroendovascular surgical techniques, the list of options able to be offered to patients with cerebral vascular pathology has grown enormously. Despite advances in equipment and technique, many treatable anomalies remain inaccessible because of pathologic and age-related features in vessels that must be traversed to reach the cerebral vasculature. This case study illustrates how the hybrid OR environment enables collaboration between surgeons from complementary subspecialties that results in net benefit to this patient with aneurysmal subarachnoid hemorrhage and forbiddingly tortuous vasculature.     

Collaboration in the Hybrid Operating Room: A Focus Group Study From the Perspective of the Nursing Staff

Technical advancements in the operating room setting continue, and the concept of the hybrid operating room is promoted and accepted worldwide. The hybrid setting means inclusion of radiology in the already complex environment of a traditional operating room. Collaboration in this type of environment becomes essential and investigating how the nursing staff experiences this collaboration in the hybrid operating room is needed. The aim of the study was to investigate how the nursing staff from the specialties of surgery, anesthesiology, and radiology experienced collaborating in a hybrid operating room. Explorative qualitative design was used. Five focus groups consisting of operating room nurses, operating room assistant nurses, nurse anesthetists, assistant nurse anesthetists, and radiographers were included in the study. Interviews using semistructured questions were conducted. Directive content analysis was used for the data analysis. The following categories revealed: (1) different patient safety perspectives; (2) responsibilities being shared and divided; (3) collaboration becoming better over time; (4) uneven division of labor in a strained work situation and different terms of employment; (5) lack of education and joint meetings; and (6) environmental constraints for satisfying collaboration. The nursing staff in the hybrid operating room highlighted they worked toward a common goal but prioritized their own specific tasks rather than the procedure as a whole. This, together with the uneven task distribution and unclear responsibilities, could create tension between the different staff categories, impacting procedures negatively. The results revealed the importance of proper preparation of the staff to work in the hybrid operating room. Having team building activities, common meetings, relevant training to meet educational needs, and adjusting the team composition could improve hybrid operating room collaboration and improve patient safety and outcomes.     

一站式杂交手术室腹主动脉瘤腔内修复术的手术配合

目的 探讨一站式杂交手术室腹主动脉瘤腔内修复术的护理配合及管理.方法 总结对41例腹主动脉瘤腔内修复术配合的护理经验.结果 利用一站式杂交手术室的优势,配备素质良好的专业护理人员,做好术前、术中、术后的各项护理操作及管理,更好地配合腹主动脉瘤腔内修复术,手术护理效果理想.结论 人力资源的合理配置、科学的护理管理、精细的手术配合是杂交手术成功的关键.     

Endovascular management of vascular trauma

Over the past several decades, catheter-based and endovascular techniques have been used with increasing frequency for the management of trauma. This is particularly true for the management of solid organ injury and vascular injuries resulting from pelvic fracture with the use of embolization techniques for successful arrest of active hemorrhage. Likewise, there is a large body of literature regarding the management of acute traumatic vascular injuries involving traditional open surgical techniques. Currently, however, there is sparse literature on the management of vascular trauma with endovascular techniques. The endovascular management of vascular trauma seems particularly appealing in the management of blunt truncal injuries, especially in the setting of severe concomitant brain and lung injury. Extremity and neck injuries are probably best handled by traditional methods of surgical proximal and distal control, the exception to this being base of skull injuries where there is no ability for distal vessel control, and "watershed" areas between the trunk and extremities where proximal vascular control can be quite difficult. This chapter reviews current literature with regard to the endovascular management of traumatic vascular injuries with regions being broadly defined as neck, trunk, and extremity.     

Azygos vein laceration following a vertical deceleration injury.

A 41-year-old man presented with respiratory distress and hypotension after a 30-foot fall from a tree. Despite fluid resuscitation, the patient expired in the operating room. Autopsy revealed an azygos vein laceration at the junction of the superior vena cava as the cause of death. Azygos vein and superior vena caval lacerations are rare following blunt chest trauma, including vertical deceleration injury. Early suspicion of vascular injuries with aggressive fluid resuscitation and surgical intervention remain the only hope for survival from this highly lethal injury.     

CT angiogram and endovascular stent graft for an axillary artery gunshot wound

A patient with an axillary artery gunshot wound pseudoaneurysm was evaluated and managed with computed tomographic angiogram and endovascular stent graft. Vascular injuries resulting from penetrating trauma or interventional vascular procedures are relatively uncommon. Subclavian and axillary arterial injuries may be associated with substantial morbidity and mortality if not managed expeditiously. The inaccessibility of these arteries makes stent graft treatment particularly attractive. The stable patient with a pseudoaneurysm or an arteriovenous fistula seems to be the ideal candidate to treat in this way. As computed tomography (CT) technology has evolved, CT angiography has become an integral part of the initial assessment of proximal extremity vascular injuries.     

下肢动脉硬化闭塞症的杂交手术治疗

目的探讨下肢动脉硬化闭塞症杂交（hybrid）手术治疗的适应证选择、手术方法及疗效分析。方法回顾性的分析我院2005年至2008年来血管杂交手术治疗20例下肢动脉硬化闭塞症的资料。根据患者介入探查情况行杂交手术治疗治疗。结果近期有效率95％。治疗后平均缈肱比值（ABI）提高0．56,足背或胫后动脉搏动者8例,占40％。结论下肢动脉硬化闭塞症血管杂交手术治疗是一种有效的治疗手段,对于复杂的动脉硬化闭塞症患者。较单一的手术或腔内治疗,具有优势互补、减少创伤、安全的特点,能最大程度的挽救肢体。     

Axillary artery transection after recurrent anterior shoulder dislocation

Axillary artery transection after recurrent anterior shoulder dislocation is extremely rare. We present 2 such patients. The first, a 62-year-old man, presented with acute ischemia and a large hematoma in the axilla and chest wall. The second, a 63-year-old man, had a pseudoaneurysm and palpable peripheral pulses. Both underwent urgent computed tomography, which confirmed the clinical diagnosis, and the patients were taken to the operating room. In the first patient, intraoperative angiogram through both the brachial and the femoral route showed complete disruption of the axillary artery rendering an endovascular approach not possible. Proximal balloon occlusion was then undertaken through the femoral artery, controlling the bleeding and allowing easier dissection of the ruptured segment. Revascularization was performed with an interposition polytetrafluoroethylene (PTFE) bypass restoring normal blood supply to the upper extremity. The second patient had a Viabhan (W.L. Gore, Flagstaff, Ariz) stent-graft implanted through the brachial artery with an excellent clinical and angiographic result. As expected, both patients had significant neurologic morbidity due to associated brachial plexus palsy. Ruptured axillary artery after shoulder dislocation is very uncommon. Endovascular repair and hybrid procedures combining open and endovascular techniques can offer reliable solutions to these challenging problems.     

神经外科杂交手术的护理配合

目的总结神经外科复杂脑脊髓血管病杂交手术的护理配合经验。方法回顾分析2011年4月-2012年5月华西医院手术室完成的56例神经外科杂交手术的临床资料,总结神经外科杂交手术的护理配合经验。结果所有手术均顺利进行,未出现明显危及患者安全的情况。结论神经外科Hybrid手术治疗复杂脑脊髓血管病较普通手术更为安全有效。但手术护理准备及配合更为复杂,在手术室布局、手术流程方面需要医护协调专门进行优化。有神经外科专业经验的护士经过一段时间专门培训后担任手术巡回及器械护士更有利于手术的顺利、安全进行。     

May-Thurner syndrome: High output cardiac failure as a result of iatrogenic iliac fistula

May-Thurner syndrome(MTS) also termed iliocaval compression or Cockett-Thomas syndrome is a common, although rarely diagnosed, condition in which the patient has an anatomical variant wherein theright common iliac artery overlies and compresses the left common iliac vein against the fifth lumbar spine resulting in increased risk of iliofemoral deep venous thrombosis. This variant has been shown to be present in over 23% of the population but most go undetected. We present a patient with MTS who developed high output cardiac failure due to an iatrogenic iliac fistula. The patient underwent an extensive workup for a left to right shunt including MRI and arterial duplex in the vascular lab. He was ultimately found to have a 2.1 cm left common iliac artery aneurysm and history of common iliac stent. We took the patient to the operating room for aortogram with placement of an endovascular plug of the left internal iliac artery and aorto-biiliac stent graft placement with CO2 and Ⅳ contrast. Subsequently the patient underwent successful stent placement in the area that was compressed followed by 6 mo of anticoagulation with warfarin. The flow from the fistula decreased significantly.     

Endovascular procedures, carotid endarterectomies, and aortic surgery should preferentially be done by a vascular trainee rather than a general surgery resident

This article is the result of a debate. The motion proposed was that "endovascular procedures, carotid endarterectomies, and aortic surgery should be done preferentially by a vascular trainee rather than a general surgery resident.' Arguments in favor of the motion were that with the development of endovascular surgery, there are now less open vascular procedures to perform and hence, vascular trainees needed to hone their skills on these limited cases rather than waste that experience on a general surgery resident. This focused training experience would allow vascular fellows to be become more highly skilled vascular surgeons. Additionally, endovascular procedures are an important component of modern vascular surgery, and it is important for the vascular fellow to develop significant experience with and acquire the appropriate numbers of endovascular cases to get the necessary credentials when going into a vascular practice. Arguments against the motion were that exposure to vascular cases will make a better general surgeon, one who will also be well equipped to deal with trauma cases and situations where the control of bleeding might be life saving. Additionally, the issue of exposure of general surgery residents to vascular cases might be a positive recruitment strategy for future vascular fellows. The motion was carried by a small majority vote.     

血管介入复合手术室单元运行模式的初步探讨

近年来,"一站式"血管介入复合手术因其多样性的手术设备、广泛的应用领域、微创的优势以及多功能手术室理念而备受瞩目。复旦大学附属中山医院血管介入复合手术室自2006年投入应用以来,已完成手术近5500例,其中不乏复杂的血管介入复合手术。本文结合复合手术室单元的运用与维护,初步探讨血管介入复合手术室的护理管理模式。     

Reducing complications of thoracic gunshot wounds

With the persistent presence of violence in our urban areas and the availability of guns, penetrating injuries as a result of firearm use continue to be a challenge for the emergency, surgery, and operating room nurse. Because gunshot wounds may be rapidly fatal, an understanding of firearms and the injuries they produce, as well as their possible complications, can assist the critical care nurse in caring for patients with gunshot wounds to the chest. Thoracic trauma is present in 50% of all trauma patients and is the cause of death in 25% of these victims. Penetrating trauma from violent episodes accounts for approximately 50% of cases of chest trauma in the urban setting.     

Drug-eluting stents for infrapopliteal arterial disease in the setting of critical limb ischemia

Peripheral artery disease is increasingly prevalent with disease presentations ranging from the asymptomatic patient to the patient with an ischemic or threatened lower extremity. The role of the vascular specialist treating the peripheral artery disease patient is to create or maintain straight-line or uninterrupted blood flow to the extremities in order to preserve patient mobility and the ability of the leg to heal in the setting of trauma or infection. Although autologous-vein surgical bypass grafting has long been viewed as the first-line treatment, endovascular approaches have become increasingly popular owing to technological advances, including the advent of drug-eluting stents. The angiographic and clinical results including symptom improvement, wound healing, limb salvage rates, cost considerations and current ongoing clinical research will be discussed.     

Emergency management of cardiac injuries

Cardiac trauma is not usually treatable in the field. EMS providers must recognize the possibility of cardiac trauma rapidly and evacuate the patient to an appropriate facility. Most therapy for cardiac trauma requires an operating room, preferably with cardiopulmonary bypass capability. Basic patient care should occur en route to the treatment facility. Ensure that the airway is intact, control respirations and bleeding, and restore circulatory volume to a pressure of about 100 systolic. Advanced providers should re-expand any associated tension pneumothorax and ensure the chest wall is stable. Consider early intubation, since operative intervention is likely.     

The effectiveness of hybrid treatment for sever multiple trauma: a case of multiple trauma for damage control laparotomy and thoracic endovascular repair

Background

Time is a crucial factor for the successful early management of the multi-trauma patient. Hybrid operating theaters, which support the integration of surgical treatment and interventional radiology, provide opportunities to reduce the time-to-surgery for life threatening conditions.

Case presentation

We describe the early successful treatment of a 54-year-old male who sustained multiple injuries when he was hit by a 1000 kg bale of wheat that fell from a height. He was admitted with hemorrhagic shock due to intra-abdominal bleeding, an unstable fracture of the pelvis, and blunt aortic injury, which was considered to be at high risk of rupture. External fixation was applied to the pelvis in the resuscitation bay, and the patient was transferred to a hybrid operating theater for treatment of both the intra-abdominal hemorrhage and blunt aortic injury. Damage control laparotomy and thoracic endovascular aortic repair were performed uneventfully.

Conclusions

Hybrid treatment, which combines emergency surgery and intraoperative interventional radiology, provides a prompt and appropriate management approach for the treatment of patients with severe multiple trauma and may improve patient outcomes.

     

A modern approach to cervical vascular trauma

Blunt or penetrating trauma to the major arteries of the neck are challenging problems, however, newer diagnostic and therapeutic modalities have simplified care and largely eliminated the need for diagnostic neck exploration. High-quality computed tomographic angiography is quick and sensitive, identifying the vast majority of injuries prior to any operative intervention. Even in cases where active exsanguination or impending airway compromise mandates immediate exploration, intraoperative imaging and endovascular interventions have largely supplanted relatively morbid exposures for open repair. Traditional open repair of carotid injuries with primary closure or interposition grafting is effective over the long term and is always recommended if proximal and distal control can be achieved in a safe and straightforward manner. Endovascular repair of the proximal carotid, proximal subclavian, and distal internal carotid arteries is increasingly accepted. However, vertebral trauma is dealt with almost exclusively by endovascular means. Recent military experiences in Iraq and Afghanistan highlight the imaging-intensive management of cervical vascular trauma and demonstrate the effectiveness of computed tomography angiography, selective arteriography, and endovascular interventions.     

Penetrating abdominal trauma

The management of patients with penetrating abdominal trauma is outlined in Figure 1. Patients with hemodynamic instability, evisceration, significant gastrointestinal bleeding, peritoneal signs, gunshot wounds with peritoneal violation, and type 2 and 3 shotgun wounds should undergo emergency laparotomy. The initial ED management of these patients includes airway management, monitoring of cardiac rhythm and vital signs, history, physical examination, and placement of intravenous lines. Blood should be obtained for initial hematocrit, type and cross-matching, electrolytes, and an alcohol level or drug screen as needed. Initial resuscitation should utilize crystalloid fluid replacement. If more than 2 liters of crystalloid are needed to stabilize an adult (less in a child), blood should be given. Group O Rh-negative packed red blood cells should be immediately available for a patient in impending arrest or massive hemorrhage. Type-specific blood should be available within 15 minutes. A patient with penetrating thoracic and high abdominal trauma should receive a portable chest x-ray, and a hemo- or pneumothorax should be treated with tube thoracostomy. An unstable patient with clinical signs consistent with a pneumothorax, however, should receive a tube thoracostomy prior to obtaining roentgenographic confirmation. If time permits, a nasogastric tube and Foley catheter should be placed, and the urine evaluated for blood (these procedures can be performed in the operating room). If kidney involvement is suspected because of hematuria or penetrating trauma in the area of a kidney or ureter in a patient requiring surgery, a single-shot IVP should be performed either in the ED or the operating room. An ECG is important in patients with possible cardiac involvement and in patients over the age of 40 going to the operating room. Tetanus status should be updated, and appropriate antibiotics covering bowel flora should be given. Operative management should rarely be delayed by procedures in the ED. Only lifesaving procedures necessary to prevent further deterioration should temporarily delay sending a patient to a waiting surgical team. Stable patients can be further evaluated in the ED. Those with stab wounds to the abdomen, flank, and selected cases of back injuries should undergo LWE. Those with negative LWE can be discharged after appropriate wound care and patient education. Patients with equivocal or positive LWE should undergo DPL. Patients with tangential gunshot wounds and possible type 2 shotgun injuries can undergo DPL. Table 8 lists the recommended thresholds for DPL. Patients with positive DPL should undergo exploration.(ABSTRACT TRUNCATED AT 400 WORDS)     

A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneurysm

BackgroundThrombosis of an endovascular aortic repair (EVAR) is a devastating complication of a common surgical procedure that can lead to serious morbidity and mortality if not promptly recognized. This is the first case report of an EVAR graft thrombosis in the emergency medicine literature.Case reportWe present a case of a patient with lower extremity paraplegia secondary to thrombosis of an EVAR graft who presented to the emergency room with acute stroke-like symptoms after a recent EVAR procedure. Endovascular repair of abdominal aortic aneurisms is becoming more frequent, and an increased number of patients with recent abdominal aortic aneurism repair by endovascular grafts will be evaluated by emergency physicians in the future. Emergency physicians should be aware that signs of limb ischemia, which may masquerade as acute ischemic stroke-like symptoms, is one of the more serious complications that can occur with abdominal aortic vascular grafts. Among patients with lower extremity neurological deficits in the recent setting of EVAR presenting to an emergency department, there should be a high degree of suspicion for EVAR graft thrombosis, which can be diagnosed via the gold standard of CT angiography or ultrasonography. Prompt vascular surgery consultation is essential to minimize permanent disability.