Neumomediastino en trauma contuso: ¿son siempre necesarios los estudios invasivos para descartar lesión aerodigestiva? / Pneumomediastinum in blunt trauma: Are invasive studies always necessary to rule out aerodigestive injury?

Introducción. La presencia de neumomediastino secundario a un trauma contuso es un hallazgo común, especialmente con el uso rutinario de la tomografía computarizada. Aunque en la mayoría de los casos es secundario a una causa benigna, la posibilidad de una lesión aerodigestiva subyacente ha llevado a que se recomiende el uso rutinario de estudios endoscópicos para descartarla. El propósito de este estudio fue determinar la incidencia de neumomediastino secundario a trauma contuso y de lesiones aerodigestivas asociadas y establecer la utilidad de la tomografía computarizada multidetector en el diagnóstico de las lesiones aerodigestivas. Métodos. Mediante tomografía computarizada multidetector se identificaron los pacientes con diagnóstico de neumomediastino secundario a un trauma contuso en un periodo de 4 años en un Centro de Trauma Nivel I. Resultados. Fueron incluidos en el estudio 41 pacientes con diagnóstico de neumomediastino secundario a un trauma contuso. Se documentaron en total tres lesiones aerodigestivas, dos lesiones traqueales y una esofágica. Dos de estas fueron sospechadas en tomografía computarizada multidetector y confirmadas mediante fibrobroncoscopia y endoscopia digestiva superior, respectivamente, y otra fue diagnosticada en cirugía. Conclusión. El uso rutinario de estudios endoscópicos en los pacientes con neumomediastino secundario a trauma contuso no está indicado cuando los hallazgos clínicos y tomográficos son poco sugestivos de lesión aerodigestiva.

Introduction.The presence of pneumomediastinum secondary to blunt trauma is a common finding, especially with the use of computed tomography. Although in most cases the presence of pneumomediastinum is secondary to a benign etiology, the possibility of an underlying aerodigestive injuries has led to the recommendation of the routine use of endoscopic studies to rule them out. The purpose of this study was to determine the incidence of pneumomediastinum secondary to blunt trauma and associated injuries and to establish the role of multidetector computed tomography in the diagnosis of aerodigestive injuries. Methods.Using multidetector computed tomography, patients with a diagnosis of pneumomediastinum secondary to blunt trauma were identified over a period of 4 years in a Level 1 Trauma Center. Results. Forty-one patients diagnosed with pneumomediastinum secondary to blunt trauma, were included in this study. Two airway ruptures were documented: two tracheal injuries and one esophageal injury. Two of them suspected on multidetector computed tomography and confirmed on bronchoscopy and esophagogastroduodenoscopy, respectively, and another was diagnosed in surgery. Conclusion.The routine use of endoscopic studies in patients with pneumomediastinum secondary to blunt trauma is not indicated when the clinical and tomographic findings are not suggestive of aerodigestive injury.

Trombosis porto-mesentérica aislada secundaria a trauma abdominal cerrado / Isolated porto-mesenteric thrombosis secondary to blunt abdominal trauma

En este artículo se revisan los aspectos más importantes de la epidemiología, fisiopatología, abordaje diagnóstico y terapéutico de la trombosis del sistema venoso portal y mesentérico, para finalizar discutiendo la experiencia clínica de un caso a la luz de la literatura relevante. Esta complicación es usualmente relacionada con afecciones sistémicas y hepáticas, pero rara vez se presenta aislada y relacionada con el trauma. En ausencia de tratamiento adecuado durante la etapa aguda, la trombosis puede evolucionar hacia el infarto intestinal y la muerte del paciente. En casos crónicos, se ha asociado con la degeneración del sistema venoso portal hacia cambios por hipertensión portal crónica

This article reviews the epidemiology, pathophysiology, diagnostic and therapeutic approach of the portal and mesenteric venous system thrombosis, with a clinical case discussion considering the relevant literature. This complication is usually related to systemic and hepatic conditions, but rarely occurs isolated and related to trauma. In the absence of adequate treatment during the acute stage, thrombosis can progress to intestinal infarction and death. In chronic cases, it has been associated with degeneration of the portal venous system into changes due to chronic portal hypertension

Clinical characteristics and treatment of traumatic renal artery thrombosis / 中华老年医学杂志

Objective To investigate the clinical characteristics,early diagnosis,and rational treatments of traumatic renal artery thrombosis or other traumatic emboli.Methods We summarized the clinical data of 10 patients with traumatic renal artery thrombosis or other traumatic emboli.Results Six of ten patients had left renal artery thrombosis,while four of the ten patients had right renal artery thrombosis.Ultrasonography reported a reduced blood flow signal in one patient,and then renal artery embolism was confirmed by enhanced CT.The other nine patients were directly definitely diagnosed as renal artery embolism by enhanced CT.Four patients were treated with low molecular weight heparin calcium,in whom the CT follow-up showed no obvious blood reperfusion in injured kidneys,but the renal function was in normal range.Renal hypertension occurred in two patients,and one of them received nephrectomy because of poorly controlled hypertension with medication.Conclusions Clinical symptoms,signs and laboratory examinations show no specific findings for diagnosis of traumatic renal artery thrombosis.The color Doppler ultrasound is a preliminary screening method for,and an enhanced CT scan is an effective method for,diagnosis of renal artery thrombosis.The early recovery of renal blood circulation is an evidence of effective treatment.Major concerns are supposed to focus on renal function and blood pressure during followup.

The diagnosis and treatment of abdominal trauma in children / 中国小儿急救医学

Objective To explore the indications of conservative treatment and to explore the laparotomy for children with abdominal trauma,so as to improve the diagnosis and treatment of abdominal injury in children.Methods This retrospective review included 89 children who had an abdominal trauma which was classified according to the injury situation.Results (1)Of 25 patients with hepatic injury,1 underwent surgery.Among the 48 patients with splenic injury,46 cases were treated successfully by conservative treatment,only 1 underwent splenectomy and another adopted splenic neoplasty.Fourteen patients suffered from gastrointestinal injury,and 4 of them underwent emergency laparotomy,however a delayed perforation of digestive tract occurred in 1 child when he was in hospital 4 days later.Eight cases of pancreatic trauma were treated successfully by conservative treatment,the same as 6 cases of renal and adrenal contusion.One child with uterus and bladder injury was atopted emergency surgical treatment.(2) Unlike adults,conservative management of hepatic and splenic injuries was successfully applied to the vast majority of children.Operative treatment ought to be carried out when hemodynamic stability could not be maintained despite a continuous intravenous fluids and blood transfusion,or when the total amount of blood transfusion exceeds 40 ml/kg.(3)CT was very useful for children with gastrointestinal injury,especially for one cannot stand for abdominal X-ray examination.Operative treatment ought to be carried out timely in those with pneumoperitoneum or abdominal distension.We should pay particular attention to the possibility of delayed perforation.(4)In general,pancreatic injury could be treated conservatively except the ones with pancreatic rupture.(5)Children with bladder and uterine injury often suffered from severe trauma,and needed to be operated timely.Conclusion Children with abdominal injury should be highly valued in primary hospital.Internal bleeding caused by substantial organ injury is the leading cause of death in children,and the delayed diagnosis and treatment of the injured cavity organs is another important cause of the death.Therefore,early accurate diagnosis,active treatment,comprehensive treatment of severe combined injuries and complications are the key to successful treatment of such patients.

Pattern of Chest Injuries in a Tertiary Care Centre in Western U.P.

Background: Chest trauma is a leading cause of morbidity and mortality among all age groups.. This retrospective study has been undertaken to analyse the pattern of chest injuries among patients admitted in a tertiary care centre. Methods: All the in-patient records of patients, admitted with abdominal injuries in the emergency department of the Teerthankar Mahaveer Medical College & Research Centre, located in Moradabad (U.P.). Results: There were total 139 cases of chest injuries, during the study period. 84 victims were in 2nd to 4th decades of life, 18 in 5th decade, 8 in 1st decade and the remaining 19 patients were in either extremes of age groups. The male to female ratio was 2.4:1. There were 111 cases of blunt chest injuries and 28 cases of penetrating injuries. Most common X ray findings were haemothorax, seen in 94 cases followed by pneumothorax in 59 cases and multiple rib fractures in 50 cases. Blunt injuries were caused due to accidents in 102 cases and homicides in 9 cases. Penetrating injuries were caused due to accidents in 15 cases and homicides in 13. The mortality rate was 6.4%. Conclusion: Chest Injuries were more common among males than females.

Pattern of Abdominal Injuries in A Tertiary Care Centre in Western U.P.

Background: Abdominal trauma is a leading cause of morbidity and mortality among all age groups. This retrospective study has been undertaken to analyse the pattern of abdominal injuries among patients admitted in a tertiary care centre. Methods: All the in-patient records of patients, admitted with abdominal injuries in the emergency department of the Teerthankar Mahaveer Medical College & Research Centre, located in Moradabad (U.P.) during the one year period from 1st December 2011 to 30th November 2012, were analysed. Results: There were total 87 cases of abdominal injuries, during the study period. 51 victims were in 2nd to 4th decades of life, 12 in 5th decade, 11 in 1st decade and the remaining 12 patients were in either extremes of age groups. The male to female ratio was 3.3:1. There were 61 cases of blunt abdominal injuries and 26 cases of penetrating injuries. Most commonly injured viscus in blunt trauma was bowel, and in cases of penetrating injuries, spleen. Blunt injuries were caused due to accidents in 57 cases and homicides in 4 cases. Penetrating injuries were also most commonly caused due to accidents in 16 cases and homicides in 10 the mortality rate was 4.6%. Conclusion: Abdominal Injuries were more common among males than females.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한구급학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한중환자의학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Fatores preditivos de lesões abdominais em vítimas de trauma fechado / Predictors of abdominal injuries in blunt trauma

OBJETIVO: Identificar fatores preditivos de lesões abdominais em vítimas de trauma fechado. MÉTODOS: Análise retrospectiva dos dados das vítimas de trauma fechado com idade superior a 13 anos, em um período de 15 meses. Comparamos as variáveis entre os doentes com lesões abdominais diagnosticadas por tomografia computadorizada e/ou laparotomia - grupo I (Abbreviated Injury Scale abdome>0, grupo I) e os demais - grupo II (Abbreviated Injury Scale abdome=0,). RESULTADOS: Foram incluídos 3783 casos, com média etária de 39,1 +17,7 anos (14 a 99 anos), sendo 76,1% do sexo masculino. Foram identificadas lesões abdominais em 130 doentes (3,4%). Os traumatizados com lesões abdominais apresentaram, significativamente, menor média etária (35,4 + 15,4 anos vs. 39,2 + 17,7 anos), menor média da pressão arterial sistólica à admissão (114,7 + 32,4mmHg vs. 129,1 + 21,7mmHg), menor média na escala de coma de Glasgow à admissão (12,9 + 3,9 vs. 14,3 + 2,0), maior média de AIS em segmento cefálico (0,95 + 1,5 vs. 0,67 + 1,1), maior média de AIS em segmento torácico (1,10 + 1,5 vs. 0,11 + 0,6) e maior média de AIS em extremidades (1,70 ± 1,8 vs. 1,03 ± 1,2). Os maiores Odds ratio foram presença de tórax flácido (21,8) e fraturas de pelve (21,0). CONCLUSÃO: As lesões abdominais foram mais frequentemente observadas nos doentes com instabilidade hemodinâmica, alteração na escala de coma de Glasgow, lesões graves em crânio, tórax ou extremidades.

OBJECTIVE: To identify predictors of abdominal injuries in victims of blunt trauma. METHOD: retrospective analysis of trauma protocols (collected prospectively) of adult victims of blunt trauma in a period of 15 months. Variables were compared between patients with abdominal injuries (AIS>0) detected by computed tomography or/and laparotomy (group I) and others (AIS=0, group II). Student's t, Fisher and qui-square tests were used for statistical analysis, considering p<0.05 as significant. RESULTS: A total of 3783 cases were included, with a mean age of 39.1 ± 17.7 years (14-99), 76.1% being male. Abdominal injuries were detected in 130 patients (3.4%). Patients sustaining abdominal injuries had significantly lower mean age (35.4 + 15.4 vs. 39.2 + 17.7), lower mean systolic blood pressure on admission (114.7 + 32.4 mmHg vs. 129.1 + 21.7 mmHg), lower mean Glasgow coma scale (12.9 + 3.9 vs. 14.3 + 2.0), as well as higher head AIS (0.95 + 1.5 vs. 0.67 + 1.1), higher thorax AIS (1.10 + 1.5 vs. 0.11 + 0.6) and higher extremities AIS (1.70 ± 1.8 vs. 1.03 ± 1.2). Patients sustaining abdominal injuries also presented higher frequency of severe injuries (AIS>3) in head (18.5% vs. 7.9%), thorax (29.2% vs. 2.4%) and extremities (40.0% vs. 13.7%). The highest odds ratios for the diagnosis of abdominal injuries were associated flail chest (21.8) and pelvic fractures (21.0). CONCLUSION: Abdominal injuries were more frequently observed in patients with hemodynamic instability, changes in Glasgow coma scale and severe lesions to the head, chest and extremities.

Abdominal organ involvement in blunt injuries.

Visceral injuries of the abdomen following blunt trauma present a great medico-legal problem to the forensic experts. Thus the doctor should remain alert to the development of signs and symptom after blunt trauma to the abdomen in vehicular accident otherwise he may be charged of negligence. Among 55 fatal cases of blunt abdominal injury, maximum number of cases belongs to the age group 20-29 yrs. Males were the predominant victims with ratio 4:1. It was found that road traffic accidents by heavy vehicle like bus; car and truck were responsible for 70% of blunt abdominal injuries. Among 55 cases of blunt injury, the incidence of the involvement of liver, spleen, small intestine, kidney, stomach and urinary bladder were 67%, 30.91%, 18%, 10.9%, 9.09%, 5% cases respectively. Genitals were found injured in 3% cases of blunt injury abdomen. For Blunt Injuries of Abdomen majority of the cases i.e. 78.18% were of accidental, 18.18% were homicidal and 3.6% suicidal in nature. Immediate cause of death was shock and hemorrhage and in those cases where death was delayed, cause of death was septicemia.

Computed Tomography of Blunt Spleen Injury: A Pictorial Review

The spleen is one of the organs most frequently injured in blunt abdominal trauma. Computed tomography (CT) scanning can accurately detect splenic injury and is currently the imaging modality of choice in assessing clinically stable patients with blunt abdominal trauma. The CT features of spleen injury include lacerations, subcapsular or parenchymal haematomas, active haemorrhage, and vascular injuries. We present a pictorial review of the spectrum of CT findings for blunt splenic injuries. This article will be a useful reference for radiologists and surgeons as CT scan is widely used for the assessment of splenic injuries and contributes to the current trend towards nonsurgical management of this injury.

Post-Traumatic Occlusion of the Proximal Subclavian Artery Without Clavicle and First Rib Fracture

Subclavian artery occlusion after blunt trauma is an extremely rare injury. This has been attributed to its wellprotected location deep in the scalene triangle, bounded by the first rib and clavicle. A case of post-traumatic occlusion of the subclavian artery with clavicle fracture was reported by Sodhi et al in 2006 and in Korea was reported by Han et al in 2001. We believe that is the first report of post-traumatic occlusion of the subclavian artery without clavicle and first rib fracture in Korea.

Multiple Intraabdominal Solid Organ Injuries after Blunt Trauma

PURPOSE: This study evaluated the characteristics and the prognosis of multiple intraabdominal solid organ injuries, including those to the liver, spleen, and kidney, after blunt trauma. METHODS: From January 2001 to March 2009, 39 patients with multiple intraabdominal solid organ injuries, which had been confirmed by contrast-enhanced computed tomography after blunt trauma, were included in this retrospective study. The injury severity score (ISS), abbreviated injury scale (AIS), revised trauma score (RTS), American Association for the Surgery of Trauma (AAST) injury grade of solid organs, initial hemodynamic status, blood gas analysis, blood transfusion, and the mortality were the main outcome measurements. RESULTS: Injured groups were classified into liver/kidney (n=17), liver/spleen (n=4), spleen/kidney (n=13), and liver/kidney/spleen (n=5) groups. Patients were older in the liver/kidney group than in the liver/kidney/spleen group (43 vs 18 years, p=0.023). The initial systolic blood pressures tended to be lower in the liver/kidney group than in the other groups (84 vs 105, 112, and 114 mmHg, p=0.087). The amounts of 24-hour packed RBC transfusion were 32 units in the liver/kidney group and 4 units in the liver/kidney/spleen group, but the difference was not statistically significant. Differences were found in neither the RTS, ISS, and AIS for head, chest, abdominal, and pelvic injuries nor the AAST injury grade for solid organ, but injuries to the chest were more severe in the liver/spleen group than in the spleen/kidney group (AIS 4.0 vs 2.8, p=0.028). Conservative treatment was the most frequent applied treatment in all groups. There were 6 mortalities : 3 due to hypovolemia, 2 to sepsis, and 1 to brain injury. Mortalities occurred only in the liver/kidney group. CONCLUSION: Patients who had intraabdominal solid organ injuries of the liver and the kidney simultaneously, tended to be transfused more at an early time after trauma, to have lower initial systolic blood pressures, and to have a higher mortality.

A Case of Native Valve Salvage for 8 Years Longstanding Ruptured Tricuspid Valve after Blunt Chest Trauma

Although very rare, the incidence of tricuspid valve regurgitation after blunt chest trauma has risen in line with the increasing rate of car accidents and steering wheel trauma. It is easy to miss the diagnosis of tricuspid valve regurgitation following blunt chest trauma because most patients feel no symptoms at trauma, and the condition is sometimes overlooked for a long period of time due to its mild symptoms. A 49-year-old man suffered dyspnea on exertion for 1 month due to right heart failure 8 years after accidentally falling from a third floor. Preoperative echocardiography revealed severe tricuspid valve regurgitation resulting from prolapse of the anterior leaflet with annular dilatation. The patient underwent tricuspid valvuloplasty with a 36-mm Carpentier tricuspid ring. Intraoperative transesophageal echocardiography showed mild tricuspid valve regurgitation. We report a case of successful native valve salvage of ruptured tricuspid valve after blunt chest trauma, and present a review of the relevant literature.

A Case of Native Valve Salvage for 8 Years Longstanding Ruptured Tricuspid Valve after Blunt Chest Trauma

Although very rare, the incidence of tricuspid valve regurgitation after blunt chest trauma has risen in line with the increasing rate of car accidents and steering wheel trauma. It is easy to miss the diagnosis of tricuspid valve regurgitation following blunt chest trauma because most patients feel no symptoms at trauma, and the condition is sometimes overlooked for a long period of time due to its mild symptoms. A 49-year-old man suffered dyspnea on exertion for 1 month due to right heart failure 8 years after accidentally falling from a third floor. Preoperative echocardiography revealed severe tricuspid valve regurgitation resulting from prolapse of the anterior leaflet with annular dilatation. The patient underwent tricuspid valvuloplasty with a 36-mm Carpentier tricuspid ring. Intraoperative transesophageal echocardiography showed mild tricuspid valve regurgitation. We report a case of successful native valve salvage of ruptured tricuspid valve after blunt chest trauma, and present a review of the relevant literature.

The Value of Grading of Pulmonary Contusion by the Chest CT Scanning

PURPOSE: Pulmonary contusion is the most common injury in patients with blunt chest trauma, and reported as 15~20% of multiple traumatic patients. In this study, we would like to predict a prognosis for pulmonary contusion easily at ED through the chest CT scanning. METHODS: We reviewed medical records and chest CT findings of 190 pulmonary contusion patients retrospectively. Both lung were devided into 4 areas, RUL +RML, RLL, LUL, and LLL (RUL: right upper lobe, RML:right middle lobe, LUL:left upper lobe, LLL: left lower lobe). 3 point were given to each area, maximally. In each area, a ratio was measured as the longest pulmonary contusion length per the transverse axis length of lung on the largest pulmonary contusion image of chest CT scan. The score can be obtained by multiplying 3 to the ratio and raising fractions not lower than 0.5 to a unit. We classified to three groups as mild (PCS 0-2), moderate (3-5), and severe (6-12) PCS groups. RESULTS: 179 patients with pulmonary contusion were classified as 94 mild, 52 moderate, 33 severe pulmonary contusion groups by PCS. As PCS was high, PRF (Pao2/ FiO2) was decreasing, number of patients treated with mechanical ventilation was increasing, ICU stay was long, and a complication rate was increasing. CONCLUSION: For patients with blunt chest trauma at ED which classified as severe PCS group (6-12), the patients need ICU admission and active treatment for a long time to reduce the mortality and complication rate.