Treatment of air leak in polytrauma patients with blunt chest injury

IntroductionPrecise diagnostics and an adequate therapeutic approach are mandatory in the treatment of air leak in polytrauma patients with blunt chest trauma. The aim of this study was to evaluate the incidence, characteristics, and management of air leak following this injury pattern.Patients and methodsData from 110 polytrauma patients was collected retrospectively. Fifty-four patients received initial treatment by chest tube placement for pneumothorax. These patients were classified into two groups, one with severe air leak and one with minor air leak. An evaluation of injury pattern, chest wall injuries in particular, duration of air leak, reason for drainage maintenance in place, hospital length of stay, ICU stay, ventilator duration, type of treatment, and the delay to surgical intervention was performed.ResultsWhereas 4 patients showed severe air leak and were subsequently scheduled for timely surgical intervention, the remaining 50 patients only showed minor air leak. Only 7 patients with minor air leak suffered from prolonged air leak (>5 days), which spontaneously resolved in all of them after a mean duration of 7.7 days (range 6–12 days). Absence of a prolonged air leak resulted in a shorter length of stay and a shorter duration of mechanical ventilation, although no statistical significance was observed.ConclusionsEarly spontaneous cessation of most minor air leaks as well as early surgical intervention for severe air leak lead to very satisfactory patient outcomes with a relatively short hospital stay in our patients. We therefore advocate early surgery for lacerations of the pulmonary parenchyma resulting in severe air leak, whereas minor air leaks can usually be treated conservatively.     

Hepatic enzymes have a role in the diagnosis of hepatic injury after blunt abdominal trauma

Introduction

Delayed diagnosis of patients with severe liver injuries is associated with an adverse outcome. As computed tomographic (CT) scan is not always available in the management of blunt abdominal trauma worldwide, the present study was undertaken to determine the accuracy of selected haematological markers in predicting the presence of hepatic injury and its severity after blunt abdominal trauma.

Methods

A retrospective review of all patients with blunt abdominal trauma presented to our institution over a 3-year period was performed. Patients were excluded if they suffered penetrating injuries, died in the emergency department or if the required blood tests were not performed within 24 h of the accident. The grading of the hepatic injury was verified using CT scans or surgical findings.

Results

Ninety-nine patients with blunt abdominal trauma had the required blood tests performed and were included in the study. The median injury severity score was 24 (range 4-75). Fifty-five patients had hepatic injuries, of which 47.3% were minor (Grades I and II) while 52.7% had major hepatic injuries (Grades III-V). There were no patients with Grade VI injuries.A raised ALT was strongly associated with presence of hepatic injuries (OR, 109.8; 95% CI, 25.81-466.9). This relation was also seen in patients with raised AST > 2 times (OR, 21.33; 95% CI, 7.27-62.65). This difference was not seen in both bilirubin and ALP.ALT > 2 times normal was associated with major hepatic injuries (OR, 7.15; 95% CI, 1.38-37.14; p = 0.012) while patients with simultaneous raised AST > 2 times and ALT > 2 times had a stronger association for major hepatic injuries (OR, 8.44; 95% CI, 1.64-43.47).

Conclusion

Abnormal transaminases levels are associated with hepatic injuries after blunt abdominal trauma. Patients with ALT and AST > 2 times normal should be assumed to possess major hepatic trauma and managed accordingly. Patients with normal ALT, AST and LDH are unlikely to have major liver injuries.     

The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal

BACKGROUND: Focused assessment with sonography for trauma (FAST) has become commonplace in the management of blunt abdominal trauma. However, newer computed tomography (CT) scanners have decreased imaging time for trauma patients and provide more detailed examination of abdominal contents. It was the aim of the current study to evaluate practice patterns of FAST and abdominal CT in blunt trauma victims. METHODS: This was a retrospective study of all blunt trauma patients (N = 299) who received at least 1 FAST examination in the emergency department by surgeons and were admitted. Patients were tracked for subsequent CT scanning, disposition from the emergency department, any operative findings, and survival. RESULTS: Twenty-one of 299 patients (7%) had a positive FAST. There were 7 deaths and 14 patients were taken directly to the operating room (OR) for control of abdominal bleeding. Thirty-one of 299 (10%) had equivocal FAST. There were 4 deaths and 8 patients were taken to the OR for control of abdominal bleeding. A total of 247 of the 299 patients had a negative FAST. CT scans were performed in 193: 15 showed a visceral injury. There were 13 deaths and 29 patients were taken to the OR (4 for bleeding). Patients with a positive FAST had a higher mortality than FAST-negative patients (P < .001) and greater likelihood for operation (P < .001). Those with equivocal FAST had a greater likelihood for operation than FAST-negative patients (P < .05). CONCLUSIONS: FAST examinations can identify patients at risk for hemorrhage and in whom operation may be needed and, therefore, can guide mobilization of hospital resources. FAST-negative patients can be managed expectantly, using more specific imaging techniques.     

Successful management of concommitant blunt injury to the trachea, esophagus, and cervical spine in a 6-year-old girl

A 6-year-old girl sustained an unusual constellation of injuries after blunt trauma sustained in a motor vehicle accident. Transection of the trachea and esophagus were managed successfully by repair through a median sternotomy while the patient was on cardiopulmonary bypass. A cervical spinal injury was fixated with halo traction and a femur fracture with internal fixation.     

The utility of chest X-ray as a screening tool for blunt thoracic aortic injury

BackgroundThe early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI.MethodsAfter IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011–12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity.ResultsA total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4–17) and median GCS was 15 (IQR 14–15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19–67%).ConclusionThe results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.     

CT scan-detected pneumoperitoneum: An unreliable predictor of intra-abdominal injury in blunt trauma

Introduction

Free intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant.

Objective

To characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy.

Design

A retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients.

Results

Of the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P < 0.001), radiographic signs of bowel trauma (P < 0.001) as well as clinical and/or radiographic seatbelt sign (P = 0.004).

Conclusions

CT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.     

Paediatric duodenal haematoma: Nonoperative management of blunt traumatic injury

Trauma is the leading cause of morbidity and mortality in the paediatric population. Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children [1]. We present a case of a massive duodenal haematoma secondary to blunt trauma that was managed nonoperatively. Several cases reports in the literature cite successful nonoperative management of duodenal haematoma by nasogastric decompression, bowel rest, and total parenteral nutrition [4], with resumed eating an average of 16 days after injury [9]. However, if the abdominal pain or obstruction fail to improve and/or resolve with medical management over seven to ten days, complications such as infarction or peritonitis are frequent, and surgical intervention may be required [3].     

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.     

Use of Polyflex Airway stent in the treatment of perforated esophageal stricture in an infant: a case report

Anastomotic stricture is a common sequela after primary repair of esophageal atresia with esophagoesophagostomy. Esophageal perforation secondary to dilatation of the stricture, and refractory stricture are not uncommon. We present a case using a Polyflex Airway stent (Boston Scientific, Natick, MA) as an alternative treatment of esophageal stricture and perforation in an infant.     

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review

IntroductionBlunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy.Presentation of caseA 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent.DiscussionBTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks.ConclusionBlunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.     

External benchmarking of trauma services in New South Wales: Risk-adjusted mortality after moderate to severe injury from 2012 to 2016

Background

Trauma centres and systems have been associated with improved morbidity and mortality after injury. However, variability in outcomes across centres within a given system have been demonstrated. Performance improvement initiatives, that utilize external benchmarking as the backbone, have demonstrated system-wide improvements in outcomes. This data driven approach has been lacking in Australia to date. Recent improvement in local data quality may provide the opportunity to engage in data driven performance improvement. Our objective was to generate risk-adjusted outcomes for the purpose of external benchmarking of trauma services in New South Wales (NSW) based on existing data standards.

Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report

IntroductionTraumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade.Presentation of caseA 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot.DiscussionAlthough the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient’s life-threatening condition.ConclusionA prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.     

Successful application of an omental pedicle flap in delayed repair of a perforated esophageal diverticulum: Report of a case

Mediastinitis resulting from a perforated esophageal diverticulum is a potentially fatal complication and the surgical treatment of persistent esophagomediastinal fistula may be difficult. In this report, we describe the successful application of an omental pedicle flap in the delayed repair of a perforated esophageal diverticulum. A 53-year-old man presented with chest and back pain and a diagnosis of perforated esophageal diverticulum was subsequently confirmed. After receiving conservative treatment, he was referred to our department and underwent surgical repair 6 months following the onset of the perforation. Through a right thoracotomy, the mucosal layer of the esophagus around the diverticulum was sutured, and an omental pedicle flap was used to cover the suture line and obliterate the fistulous tract. His postoperative course was uneventful and the suture line healed well. The successful treatment of this patient reinforces our belief that wider application of the omental pedicle flap can be expected in the field of thoracic surgery.     

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia

Background

Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept.

Isolated colonic tuberculous perforatio as a rare cause of peritonitis: Report of a case

We present herein the rare case of a patient who developed peritonitis due to colonic tuberculosis with perforation. The patient was successfully treated by resectional surgery with delayed restoration of bowel continuity and antitubercular therapy.     

Multiple gastric ruptures caused by blunt abdominal trauma: report of a case

We report a rare case of four separate gastric ruptures resulting from blunt abdominal trauma that were successfully repaired by primary closure. A 22-year-old man injured in a motorcycle accident was admitted to our hospital where physical and radiological examinations confirmed the need for abdominal exploration. Laparotomy revealed four full-thickness lacerations in the anterior wall of the stomach. The lacerations were repaired primarily by a two-layer closure. The patient recovered gradually, and was discharged on hospital day 41, since when he has remained well. Although there has been no previous report of as many gastric lacerations following blunt abdominal trauma, surgeons should be aware of the possibility of multiple ruptures, which can be managed by simple closures. Received: August 6, 2001 / Accepted: May 7, 2002 Reprint requests to: K. Ishikawa     

掌侧锁定加压钢板与外固定支架治疗不稳定桡骨远端C型骨折的比较研究

目的比较研究掌侧锁定加压钢板（LCP）与外固定支架固定治疗不稳定桡骨远端C型骨折的疗效及适应证。方法2000年1月-2006年6月分别采用外固定支架和掌侧LCP结合克氏针撬拨、植骨等技术治疗不稳定桡骨远端C型骨折61例（85侧），骨折按AO／ASIF分型：C1型28侧，C2型33侧，C3型24侧。其中掌侧LCP治疗组34侧，外固定支架固定组51侧。比较两组手术前后掌倾角、尺偏角、桡骨短缩及关节活动范围等，初步评价其临床疗效。结果所有患者经6～27个月（平均16个月）随访。掌倾角、尺偏角、桡骨短缩及关节面均获明显改善。腕关节功能按Gartland—Werlev标准评定，C1、C2型骨折LCP组优于外固定支架组，差异有统计学意义（P〈0．05）；C3型骨折两组差异无统计学意义（P〉0．05）。结论对于掌侧或背侧不稳定的C1、C2型桡骨远端骨折，掌侧LCP可提供有效固定及早期活动；背侧不稳定的C型桡骨远端骨折是外固定支架的最佳适应证；严重粉碎的C3型骨折（尤其掌侧不稳定者）应联合运用LCP和外固定支架等技术。