Ultrasound detection of blunt urological trauma: a 6-year study

The objective of this study was to assess the utility of emergency ultrasonography in the detection of blunt urological injury. A retrospective review was conducted of all consecutive emergency blunt trauma ultrasonograms (US) obtained at a level I trauma centre from January 1995 to January 2001. Among the 4320 emergency ultrasonograms performed, 596 patients (14%) had intraabdominal injury and, of these, 99 patients (17%) had urological injuries. The sensitivity of ultrasound for all urological injuries was 67%, and specificity was 99.8%. For isolated urological injuries, sensitivity and specificity were 55.6 and 99.8%, respectively. Ultrasound was most accurate in the detection of grade III renal injuries, identifying 14/15 (93%), and 13 underwent laparotomy. For isolated urological injuries, 15 of 25 (60%) patients with a true-positive US underwent laparotomy compared to 3 of 20 (15%) with a false-negative US. Isolated urological injury was significantly associated with an ultrasonographic pattern of free fluid in the left upper quadrant and the left pericolic gutter (odds ratio=55.1; P<0.001), followed by isolated fluid in the left pericolic gutter (odds ratio=8.6; P=0.04). Although emergency ultrasonography is useful in the triage of patients with blunt urological trauma, it may miss significant urological injury requiring further intervention. As most renal injuries may be managed non-operatively, further studies such as contrast-enhanced CT or angiography should be obtained in the stable patient with suspected blunt urological injury.     

Reconstruction of the Chest Wall

Three cases of large chest wall defects necessitating reconstructive procedures, are described. Two of them followed radical resection of chondro-sarcomas and one after earlier unorthodox thoracotomy. A reconstructive technique including costal grafts (homo- or auto-grafts), two layers of fascia lata or dacron nets and bone-chips, is presented and recommended.     

Gall bladder injuries as part of the spectrum of civilian abdominal trauma in South Africa

BACKGROUND: Trauma to the gall bladder is rare, but when missed or improperly managed it may be associated with significant morbidity. The aim of the present study was to review the management and outcomes of gall bladder trauma in a trauma centre. METHODS: Forty-three patients with gall bladder injury due to abdominal trauma were reviewed over a 3-year period. Surgical management, associated injuries, morbidity and mortality rates were determined. RESULTS: Among 1242 patients undergoing laparotomy for acute trauma, 43 patients (3.46%) with gall bladder injuries were identified. Forty patients sustained penetrating injuries (37 with gunshot wounds and three with stab wounds), and three patients suffered from blunt trauma. All patients with gall bladder injury underwent abdominal exploration because of associated intra-abdominal injuries. Thirty-six patients were treated with cholecystectomy, four patients underwent primary suture repair of the gall bladder perforation, while three patients with gall bladder injury were treated without any surgical intervention at laparotomy. No complications could be attributed to the gall bladder trauma or surgery. CONCLUSION: Cholecystectomy is the preferred procedure of choice for gall bladder injuries and is associated with no morbidity.     

Chest trauma

This article summarises major life-threatening injuries in thoracic trauma. Timing, clinical features, necessary investigations and interventions are described within the clinical approach of primary and secondary surveys. Emphasis is on immediate resuscitation with some discussion on further management. Injuries included are tension pneumothorax, open pneumothorax, massive haemothorax, pericardial tamponade, aortic injuries, cardiac injuries, lung contusion, flail chest, diaphragmatic injury, airway injury and oesophageal rupture.     

Chest trauma

This article summarizes major life-threatening injuries in thoracic trauma. It explores the immediate approach to a patient presenting with thoracic trauma including diagnostics and pertinent invasive procedures. This is followed by an overview of the clinical features, investigation and management of specific life-threatening injuries that can occur in blunt and penetrating trauma. Airway injuries, chest wall and lung parenchyma injuries, cardiac and aortic injuries and diaphragmatic injuries are covered.     

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.     

Imaging limitations in evaluating blunt cardiac trauma: A case report

A 20‐year old male presented with life‐threatening polytrauma secondary to a motor vehicle accident. He had sustained injuries to the chest, including blunt cardiac trauma. On a short‐term follow‐up imaging, it was determined the patient had an injury to the main pulmonary artery and possible pericardial rupture. Given these imaging findings, he was taken to the operating room for emergent surgical intervention. Surgery revealed intracardiac injury; however, the pulmonary artery was intact. This case report is significant for the following two learning points: (a) The potential limitations of computed tomography when assessing intrathoracic injury, and (b) unique constellation of injuries secondary to trauma.     

Trauma in children: abdomen and thorax

The commonest cause of death in children in developed countries is trauma, accounting for over 350 deaths/year in the UK. In children, about 75% of trauma occurs on the roads and the majority of these involve blunt trauma with most children sustaining multiple injuries. It is more common in boys (about two- to threefold) and in the summer. The age distribution is bimodal with peaks affecting toddlers and teenagers. Mortality and morbidity have been reduced by preventative strategies, for example traffic calming systems, road safety programmes, seat belts, better car design and bicycle helmets. Once injured, swift management by skilled staff in a trauma network gives the best results and key to this are care in transport, and recognition and management of the injuries and finally rehabilitation. Important strategies for major trauma include what has become known as ‘damage limitation surgery’. In children, the absence of a plausible mechanism of injury should raise the suspicion of child abuse, and a plausible mechanism but an unusual situation might suggest neglect (e.g. a skate board injury in an 8-year-old at 23:00 hours).     

儿童闭合性肝外伤治疗体会

目的　探讨儿童闭合性肝外伤的治疗经验和体会。方法　作者回顾性分析了 1995～ 2 0 0 3年所有闭合性肝外伤的临床病例共有 30例。。均有明确的腹部外伤史。创伤原因以车祸伤居首位 ,其次为撞击伤和坠落伤。运用 PTS和 AAST对肝外伤程度作评估。结果　根据 AAST分级 , 级肝外伤 2例 , 级肝外伤 4例。其中 3例手术 ,1例死亡。PTS评分≤ 8有 3例 ,PTS>8有 2 7例。其中有 2例手术。30例患者中 ,共有 5例作手术治疗 ,包括部分肝切除和肝、大血管修补术 ,占总数的 16 .7% ,其余 2 5例均作保守治疗。在所有患者中 ,并发肝脓肿 2例 ,腹腔感染 2例 ,腹腔包裹性积液 3例 ,胸水 4例。其中 1例肝脓肿和 2例包裹性积液作外引流。除 1例死亡外 ,其余 2 9例患者均恢复良好。结论　儿童闭合性肝外伤的治疗以保守治疗为主。运用 PTS外伤评分和 AAST分级对肝外伤的严重程度作出初步评估 ,对治疗和预后有积极作用 ,在治疗过程中 ,综合分析和评价显得尤为重要     

Management of near fatal blunt laryngeal trauma

Blunt laryngeal trauma is uncommon, difficult to diagnose and recommended assessment and management guidelines differ. Mortality can be as high as 40%. Initial symptoms might mask the seriousness of the injury and a history of trauma is important. This report describes a case which illustrates many of the difficulties encountered. A high index of suspicion is needed, and all patients with a suspected blunt laryngeal injury, even with minor symptoms, should be taken seriously and considered for early precautionary airway intervention.     

Penetrating thoracic trauma

Penetrating thoracic trauma is usually an urban crime that is best managed in a trauma centre. Frequently however, it presents to emergency departments without immediate access to a cardiothoracic service. This article aims to help the general surgeon and emergency room doctor provide definitive care or stabilize the situation until specialist assistance becomes available. Appropriate immediate intervention in this situation can reduce mortality and decrease longer-term morbidity. Reasons to involve a thoracic surgeon during the patient's recovery period are also discussed.     

Management of urethral lesions in penile blunt trauma

BACKGROUND: Traumatic lesions to the penis may extend into the corpus spongiosum, causing laceration or complete transection of the urethra. Blunt penile trauma is usually related to sexual intercourse or manipulation. The aim of this paper was to report the authors experience with the management of urethral injuries in patients with penile blunt trauma. METHODS: The charts from 77 patients with penile blunt trauma were retrospectively reviewed, and the cases associated with urethral injuries associated were selected. Patient age ranged from 18 to 63 years (mean 33 years). RESULTS: From 77 cases assessed, 11 (14.2%) patients had urethral injury, 62 (80.5%) had injury of the corpora cavernosa and four (5.2%) had injury of the dorsal vein. The etiology of urethral injuries was sexual intercourse in 10 patients (91%) and direct trauma to the flaccid penis in one patient (9%). A partial urethral disruption was presented in eight patients (72.8%) and a total disruption in three patients (27.2%). Preoperative urethrogram was performed in seven patients with a suspicion of urethral trauma. When a partial injury was present the urethra was closed over the catheter, and in the presence of a total injury an end-to-end anastomosis was performed. CONCLUSION: The data support the reported incidence of urethral injury associated with blunt penile trauma. No clinically apparent urethral structures were appreciated with primary urethral repair after a follow up of more than 6 months.     

Vascular trauma

The incidence and type of vascular injury differs in different geographical locations. Blunt and iatrogenic injuries are the two commonest causes of vascular trauma in most European countries including the UK. However, in the USA, most vascular injuries are the result of stab or gunshot wounds. Vascular injuries are associated with high morbidity and mortality. They require a clear concept of the management and timely intervention in order to avoid early and late complications. This article outlines the basic principles in the management of vascular trauma.     

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.     

Blunt chest trauma in childhood

BACKGROUND: Although thoracic injuries are uncommon in children, their rate of morbidity and mortality is high. The aim of this study was to evaluate the clinical features of children with blunt chest injury and to investigate the predictive accuracy of their paediatric trauma scores (PTS). METHODS: Between September 1996 and September 2006, children with blunt thoracic trauma were evaluated retrospectively. Clinical features and PTS of the patients were recorded. RESULTS: There were 27 male and 17 female patients. The mean age was 7.1 +/- 3.4 years, and the mean PTS was 7.6 +/- 2.4. Nineteen cases were injuries caused by motor vehicle/pedestrian accidents, 11 motor vehicle accidents, 8 falls and 6 motor vehicle/bicycle or motorbike accidents. The following were noted: 28 pulmonary contusions, 12 pneumothoraxes, 10 haemothoraxes, 9 rib fractures, 7 haemopneumothoraxes, 5 clavicle fractures and 2 flail chests, 1 diaphragmatic rupture and 1 pneumatocele case. The cut-off value of PTS to discriminate mortality was found to be < or = 4, at which point sensitivity was 75.0% and specificity was 92.5%. Twenty-seven patients were treated non-operatively, 17 were treated with a tube thoracostomy and two were treated with a thoracotomy. Four patients who suffered head and abdominal injuries died (9.09%). CONCLUSION: Thoracic injuries in children expose a high mortality rate as a consequence of head or abdominal injuries. PTS may be helpful to identify mortality in children with blunt chest trauma. Blunt thoracic injuries in children can be treated with a non-operative approach and a tube thoracostomy.     

Delayed blow-out type rupture of the right ventricle following blunt chest trauma

A 36-year-old man suffered multiple traumatic injuries when he fell from a crane. Fractures of both lower extremities, a compression fracture of the fourth lumbar vertebra, and bilateral hemopneumothoraxes were identified. The sternum was not fractured, but was tender. The day after admission, the right ventricular free wall ruptured and was diagnosed by echocardiography. An emergency operation was performed. A Gore-tex^? sheet was sutured from inside the ventricle, and a Hemashield^TM graft was sutured over the tear. The risk of hemorrhage is high in the patient with multiple traumatic injuries when heparin is required. Mechanical ventilation was required until the 13^th postoperative day because persistent hemothorax. After an operation to reduce a leg fracture, the patient was discharged from the hospital on the 66^th postoperative day.     

闭合性肝外伤的非手术治疗决策(附105例报道)

目的:探讨闭合性肝外伤非手术治疗的选择。方法:回顾性分析15年来两所医院急诊收治的闭合性肝外伤患者的临床资料,结合近年国内外相关文献,从流行病学角度分析国内在不同时期闭合性肝外伤非手术治疗的选择、影响因素、结果的异同及变化。结果:国内闭合性肝外伤非手术治疗比例近8年明显升高,成功率有所下降,CT检查应用还不充分,治疗方案选择观念较陈旧。结论:非手术治疗是闭合性肝外伤治疗的重要手段,血流动力学稳定或经复苏稳定的患者均可列为候选对象;应适当扩大CT检查指征;观念更新很有必要。