Left atrial rupture following blunt thoracic injury. Case report.

A 22-year-old man presented with intermittent tachycardia and left-sided flail chest after an automobile accident. Initially his condition was stable, but 7 hours after the injury cardiac asystole appeared. Cardiopulmonary resuscitation was immediately begun and operation was performed. A rupture of the left atrium was successfully repaired without cardiopulmonary bypass.     

Vascular injuries following blunt polytrauma

Introduction

Motor vehicle collisions account for the majority of blunt vascular trauma. Much of the literature describes the management of these injuries in isolation, and there is little information concerning the incidence and outcome in patients suffering multiple trauma. This study was undertaken to describe the spectrum of blunt vascular injuries in polytrauma patients.

Patients and methods

All patients who had sustained blunt vascular trauma over a 6-year period (April 2007–March 2013) were identified from a prospectively gathered database at the Level I Trauma Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The retrieved data consisted of age, sex, mechanism of injury, referral source, Injury Severity Score (ISS), New Injury Severity Score (NISS), time from injury to admission, surgical intervention and outcome. The initial investigation of choice for patients sustaining multiple injuries was computed tomography (CT) angiography if they were physiologically stable, followed by directed angiography if there was doubt concerning any vascular lesion. If technically feasible, endovascular stenting was the preferred option for both aortic and peripheral vascular injuries.

Results

Of 1,033 patients who suffered blunt polytrauma, 61 (5.9 %) sustained a total of 67 blunt vascular injuries. Motor vehicle collisions accounted for 92 % of the injuries. The median ISS was 34 [interquartile range (IQR) 24–43]. The distribution of blunt vascular injuries was extremity (21), thorax (20), abdomen and pelvis (19), and head and neck (7). Endovascular repair was employed in 12 patients (ten blunt aortic injury, one carotid-cavernous sinus fistula, one external iliac artery). Of the extremity injuries, primary amputation was undertaken in 8 (38.1 %) and secondary amputation in 2 (9.5 %). The total amputation rate was 48 %. There were 17 (28.3 %) deaths, of which 11 (64.7 %) were directly attributable to the vascular injury and 6 (35.3 %) of these occurred on the operating table from exsanguination, the majority from injuries to the abdominal vena cava.

Conclusions

Blunt vascular injury is uncommon in the patient with multiple trauma but confers substantial morbidity and mortality. In those cases with peripheral injuries, delays in referral to definitive care frequently exceed the ischaemic time, resulting in a high rate of amputations. Central injuries, especially those of the vena cava, account for the majority of directly attributable deaths.

     

Isolated rupture of the intact gallbladder following blunt abdominal injury]

Isolated injury of the intact gallbladder following obtuse abdominal injury is rare. In connection with one case authors give a literary review of the occurrence of this injury. The pathogenesis of the rupture of the gallbladder, the clinical course and the difficulties of diagnosis are analysed.     

Atrial rupture due to blunt chest trauma

Atrial rupture by blunt trauma is lethal and one of controversial problems for cardiovascular surgeons, because of complexed conditions due to multiple organ injuries. Some papers recommend strategy of early diagnosis and treatment at an acute phase for better clinical course, but high mortality rate has not been improved yet, especially that of left atrial rupture. Three patients were reffered to our hospital by blunt chest trauma, one of whom died due to hemorrhagic shock before receiving surgical or interventional treatment. The remaining 2 patients had surgical operations at an early phase and were discharged without severe complications. We review our strategy of atrial rupture of blunt chest trauma. At an acute phase, atrial rupture alone should be repaired urgently unless use of cardiopulmonary bypass is contraindicated by severe hemorrhage of the other organs.     

Natural history of minimal aortic injury following blunt thoracic aortic trauma

Background

Endovascular repair of blunt traumatic thoracic aortic injuries (BTAI) is common at most trauma centres, with excellent results. However, little is known regarding which injuries do not require intervention. We reviewed the natural history of untreated patients with minimal aortic injury (MAI) at our centre.

Methods

We conducted a retrospective database review to identify all patients with a BTAI between October 2008 and March 2010. The cohort comprised patients initially untreated because of the lesser degree of injury of an MAI. We reviewed initial and follow-up computed tomography (CT) scans and clinical information.

Results

We identified 69 patients with a BTAI during the study period; 10 were initially untreated and were included in this study. Degree of injury included intimal flaps (n = 7, 70%), pseudoaneurysms with minimal hematoma (n = 2, 20%) and circumferential intimal tear (n = 1, 10%). Six (60%) patients were male, and the median age was 40 years. Duration of clinical follow-up ranged from 1 month to 6 years (median 2 mo) after discharge, whereas CT radiologic follow-up ranged from 1 week to 6 years (median 6 wk). Seven (70%) patients had complete resolution or stabilization of their MAI, 1 (10%) with circumferential intimal tear showed extension of the injury at 8 weeks postinjury and underwent successful repair, and 2 (20%) were lost to follow-up.

Conclusion

There appears to be a subset of patients with BTAI who require no surgical intervention. This includes those with limited intimal flaps, which often resolve. Radiologic surveillance is mandatory to ensure MAI resolution and identify any progression that might prompt repair.     

Unsuspected tracheal rupture in blunt thoracic trauma

The purpose of this report is to describe the discovery and management of an unanticipated injury during fibreoptic tracheal intubation. A 23-yr-old man sustained blunt cervical, thoracic and abdominal trauma in a motor vehicle accident. He was brought to the operating room for urgent management of his abdominal and cervical spine injuries. Examination of his airway during awake fibreoptic tracheal intubation revealed an unexpected tracheal injury. Surgical repair of the trachea was uneventful. The diagnosis and airway management of tracheal rupture are discussed. This case illustrates the importance of a full diagnostic examination during invasive anaesthetic procedures such as tracheal intubation.     

Combined blunt rupture of the diaphragm and thoracic aorta

Two patients with blunt traumatic rupture of the diaphragm and thoracic aorta are presented. This combination of injuries may be seen in the multiply-injured patient. Correct interpretation of chest radiographs is essential. If the diagnosis is made early the patient has a good chance of surviving. The eventual functional impairment is mainly related to the associated fractures.     

Laparoscopic cholecystectomy for isolated traumatic rupture of the gallbladder following blunt abdominal injury

Gallbladder rupture following blunt abdominal trauma is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. Delay in the diagnosis of the injury for several days due to no, or vague, symptoms and an insidious course is common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered isolated gallbladder rupture due to blunt abdominal trauma from a fall. We propose laparoscopic cholecystectomy as a safe and effective surgical treatment for this solitary injury.     

Diagnosis and surgical treatment of craniocerebral trauma within the scope of polytrauma management

Head trauma of different degrees is present in about two-thirds of multiple trauma patients admitted to hospital. As the primary brain damage is irreversible, our objective should be the recognition and specific treatment of both early and late complications. Stabilization of cardiorespiratory parameters must first be achieved. Secondly, only the diagnosis and treatment of life-threatening hemorrhages is of greater importance than the diagnostic and therapeutic measures undertaken by the neurosurgeon. Coma is assessed according to the Glasgow Coma Scale. The indications for CT investigation in trauma patients are: (1) loss of consciousness for more than 30 min (GCS score under 8); (2) manifest neurological deficit; (3) open head injury; (4) deterioration of clinical and neurological status after admission; (5) skull fracture. An algorithm for the management of head trauma, including the above-listed criteria and based on Schweiberer's "Graduated Schedule for Diagnosis and Treatment of Multiple Trauma" is presented. We also list the indications for urgent early neurosurgical intervention: (1) space-occupying intracranial hemorrhages, epi- or subdural, and intracerebral; (2) open head injury; (3) space-occupying impression fractures; (4) any combination of the above. In some cases neurosurgery may be performed after further stabilization, e.g., in: (1) fronto- and otobasal injuries (the latter often heal spontaneously); (2) small contusions; (3) not-space-occupying extracerebral hematomas with no tendency to increase; (4) not-space-occupying impression fractures. As soon as neurological deficit appears in the presence of one of the above, operative treatment is mandatory.     

Acute aortic valvular incompetence following blunt thoracic deceleration injury: case report

Blunt trauma leading to aortic valvular incompetence is rarely encountered, with 27 cases reported to date. All cusps and commissures are involved to a similar degree. Treatment includes either reattachment of cusps to the annulus (80% recurrence of incompetence) or valvular replacement (no recurrence). Valve replacement is the treatment of choice for these patients.     

Surgical repair of rupture of the membranous septum after blunt chest trauma

Rupture of the membranous septum is a very rare complication of blunt chest trauma. In this report, we describe a 22-year-old man who sustained multiple blunt trauma injuries during a motor vehicle accident. Rupture of the membranous septum was diagnosed 48 hours after the initial trauma and the defect was closed with Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ). However, the operation was complicated by complete atrioventricular block requiring implantation of a permanent DDD pacemaker.