Blunt renal trauma in childhood. Features indicating severe injury

The clinical presentation of children with blunt renal trauma may differ from that of adults. The clinical features at presentation of 50 consecutive children (20 severe injuries, no pedicle injuries) admitted over a period of almost 8 years were reviewed to determine if there were clinical clues to major renal trauma in childhood. Gross haematuria and low haematocrit were the most helpful factors at the time of presentation and correlated well with severe renal injury. Hypotension was seen in 4 patients and only 1 had severe renal trauma. Suspicion of a major renal injury should be high when there is gross haematuria or a low haematocrit. In this study only 1 of 20 patients with major renal injury demonstrated clinical signs of shock. Unlike adults, hypotension does not appear to be a reliable indicator of the severity of renal injury in children and diagnostic evaluation should not be reserved only for those in shock.     

Blunt trauma in soccer. The initial manifestation of synovial sarcoma

Report on a young man, who was operated upon after adequate trauma following the diagnosis "organizing haematoma of the adductorial compartment". Surprisingly we found intraoperatively tumor suggilations. According to the definition of Enneking the surgical procedure was finished as "marginal excision" and the patient was referred to an oncological center. After multimodal therapy the patient is meanwhile tumor and recurrence free for 5 years. In case of such an unexpected diagnosis the importance of paying attention to the criterias of an "incisional biopsy" is emphasized. The concept of a "conceived biopsy" is explained in preoperatively malignant looking tumors. The outstanding responsibility of the surgeon for prognosis (local recurrence) and patients quality of life (amputation versus limb salvaging) is elaborated.     

Blunt carotid artery injury after minor facial trauma

A healthy young man presented three days after suffering a punch to the face resulting in minimally displaced mandibular fractures. History revealed an episode of anterograde amnesia and a delayed episode of dysphonia. Apart from the fractured mandible, the physical examination was otherwise noncontributory. Imaging revealed severe luminal narrowing of the left cervical internal carotid artery distal to the carotid bifurcation, consistent with carotid dissection; and two focal hypodensities in the left frontal and parietal cortices, highly suggestive of acute secondary embolic infarcts. The patient was treated with systemic anticoagulation for three months and experienced no further neurological symptoms. His mandibular fractures, treated conservatively, healed without any complications.Blunt carotid artery injuries are uncommon and diverse. Neurological symptoms may develop in a delayed fashion, thus, a high index of suspicion based on knowledge of the injury mechanisms and patterns of associated injuries may enable earlier diagnosis and treatment. Angiographic imaging is essential for the diagnosis and classification of injury characteristics (eg, type, location, etc). Treatment must be considered on an individual patient basis depending on the presentation, grade and morphology of the lesion. Although no level I clinical trials exist on the topic, anticoagulation seems to be the treatment of choice in most cases and surgical intervention is not commonly indicated. Carotid artery dissection without complete thrombosis may be effectively treated with systemic anticoagulation or antiplatelet therapy in the majority of cases.     

Blunt trauma: combined anterior urethral and bladder ruptures in one patient

The combined injuries of bladder rupture and anterior urethral tear without evidence of pelvic fracture or perineal injury are described. The injuries, the result of blunt trauma, were successfully repaired surgically. This combination has not previously been noted at the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems (MIEMSS), a major regional center for blunt trauma.     

Blunt cerebrovascular injury: an evaluation from a major trauma centre

BACKGROUND: Blunt cerebrovascular injury (BCVI), although uncommon, is associated with substantial morbidity and mortality and remains poorly understood. This study was conducted to determine the pattern and outcome of BCVI at a major trauma centre. METHODS: A retrospective review of all trauma admissions between 1996 and 2004 at Liverpool Hospital, the major trauma service for south-west Sydney, was undertaken using the hospital's computerized trauma registry. RESULTS: Fourteen of the 7788 (0.18%) admitted blunt trauma patients sustained BCVI. Blunt carotid injury occurred in 10 of 14 and blunt vertebral injury occurred in 4 of 14 patients. Road trauma accounted for 9 of 14 cases. The median time to diagnosis was 2 days (range 1-45 days). The stroke rate was 36%, and the overall mortality was 29%. CONCLUSION: This study identified BCVI as a relatively infrequent occurrence but with significant mortality and morbidity rates. Practice guidelines for both the screening and management of this patient group need to be developed and introduced in this major trauma centre.     

Blunt pancreatic trauma and pseudocyst: management of major pancreatic duct injury

When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.     

Blunt diaphragmatic rupture--a rare injury in blunt thoracoabdominal trauma

INTRODUCTION: Blunt traumatic rupture of the diaphragm is rare. DISCUSSION: We provide a case report of rupture of the diaphragm with visceral herniation in blunt thoracoabdominal trauma.     

Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome

Background

The epidemiology of pediatric blunt intraabdominal arterial injury is ill defined. We analyzed a multiinstitutional trauma database to better define injury patterns and predictors of outcome.

Methods

The American College of Surgeons National Trauma Database was evaluated for all patients younger than 16 years with blunt intraabdominal arterial injury from 2000 to 2004. Injury distribution, operative treatment, and variables associated with mortality were considered.

Results

One hundred twelve intraabdominal arterial injuries were identified in 103 pediatric blunt trauma patients. Single arterial injury (92.2%) occurred most frequently: renal (36.9%), mesenteric (24.3%), and iliac (23.3%). Associated injuries were present in 96.1% of patients (abdominal visceral, 75.7%; major extraabdominal skeletal/visceral, 77.7%). Arterial control was obtained operatively (n = 46, 44.7%) or by endovascular means (n = 6, 5.8%) in 52 patients. Overall mortality was 15.5%. Increased mortality was associated with multiple arterial injuries (P = .049), intraabdominal venous injury (P = .011), head injury (P = .05), Glasgow Coma Score less than 8 (P < .001), cardiac arrest (P < .001), profound base deficit (P = .007), and poor performance on multiple injured outcomes scoring systems (Revised Trauma Score [P < .001], Injury Severity Score [P = .001], and TRISS [P = .002]).

Conclusion

Blunt intraabdominal arterial injury in children usually affects a single vessel. Associated injuries appear to be nearly universal. The high mortality rate is influenced by serious associated injuries and is reflected by overall injury severity scores.     

Blunt thoracic trauma

The majority of blunt thoracic injuries occur in the setting of multiple trauma and are often missed or underestimated. Most can be managed non-operatively, heal well and are not the major cause of long-term physical disability. The fact that surgical intervention is not usually necessary does not mean it is never required. We aim to describe the non-operative early interventions, with appropriate use of chest drains, oxygenation, pain relief and management of pulmonary secretions, that are the basis of successful treatment. We also describe the situations where the recovering patient will benefit from the opinion of a thoracic surgeon.     

Blunt thoracic trauma

Blunt thoracic trauma (BTT) accounts for 98% of thoracic trauma and can be isolated or part of the polytrauma. There are two well-defined strata of patients who present with BTT.The first group are patients with high-energy injuries which tend to have multi-trauma and are critically ill. The aim in managing these patients is to identify life-threatening underlying injuries and stabilize the patients as much as possible prior to referring to thoracic surgery. Occasionally, the need for urgent surgery by a thoracic surgeon is required, but in most cases minor procedures which can be performed in the emergency department (ED) of a district general hospital are warranted as a first measure prior to transferring the patient. The second group are the patients with isolated low-energy thoracic trauma with rib fractures and some underlying complications. The treatment of these patients tends to concentrate on respiratory support and effective analgesia and secretion clearing strategies. Increasingly there is a trend to perform surgical fixations for multiple rib fractures to achieve better analgesia and faster recovery, and to prevent prolonged ventilation. This article offers guidance on the management of patients with blunt chest trauma prior to referring to thoracic surgery.     

Blunt thoracic trauma

The restructuring of emergency healthcare services has led to more blunt thoracic trauma being treated by a multidisciplinary team, including general, orthopaedic and trauma surgeons, often without immediate access to a thoracic surgeon. Having a critical mass of injured patients in a central location, it has been possible to bring expertise from other areas of intensive care, radiology and surgery and apply new technology and techniques to the trauma patient. We now see the regular use of endovascular stenting and embolization reducing the need for urgent surgery on unstable patients and the increasing use of extracorporeal membranous oxygenation (ECMO) to salvage patients with acute respiratory distress syndrome. A more liberal use of video-assisted thoracic surgery (thoracoscopic) decortication and chest wall fixation both reduce ICU requirements and shorten hospital stay. It is hoped that these improvements in the hospital management of chest injuries will not only improve survival, but that the reduction in the late sequelae of chronic pain and loss of stamina will translate into improved return-to-work rates.     

Blunt thoracic trauma

Blunt thoracic trauma represents a significant portion of trauma admissions to hospitals in the United States. These injuries are encountered by physicians in many specialities such as emergency medicine, pediatrics, general surgery and thoracic surgery. Accurate diagnosis and treatment improves the chances of favorable outcomes and it is desirable for all treating physicians to have current knowledge of all aspects of blunt thoracic trauma. Cardiothoracic surgeons often treat the most severe forms of blunt thoracic injuries and we review the aspects of blunt thoracic trauma that are pertinent to the practicing cardiothoracic surgeon.