Clinical use of Macklin-like radiological sign (Macklin effect): A systematic review.

INTRODUCTION: Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin. METHODS: PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin. RESULTS: Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma. CONCLUSIONS: Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.

Bilateral Hyphema - An Unexpected Complication of Exercise Resistance Band Use: A Case Report.

BACKGROUND: Resistance bands commonly used for strength training exercise come with an unexpected risk for ocular trauma. CASE REPORT: In this report, we describe an unintended consequence of a 28-year-old man sustaining an unusual injury-bilateral hyphema-as a result of the use of elastic resistance bands. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Resistance bands are commonly used for strength training exercise and, in this case, a potentially severe, vision-threatening injury-traumatic hyphema-occurred. Traumatic hyphema occurs when blood pools in the anterior chamber of the eye, usually as the result of blunt force trauma or penetrating injury. Early recognition of this condition is imperative, as complications of traumatic hyphema, such as intraocular hypertension or rebleeding, can lead to permanent vision loss.

Life threatening rupture of the diaphragm after Covid 19 pneumonia: a case report.

BACKGROUND: The incidence of diaphragmatic rupture is low; however, it may be life threatening. Normally caused by blunt trauma, some cases are reported after pulmonary infections with extensive coughing. Covid 19 causes pulmonary infections and pneumonia and has been associated with weakening of the diaphragm after prolonged ventilation. We present a patient who suffered from diaphragmatic rupture 2 months after recovering from a severe Covid 19 pneumonia. CASE: A 71 years old male patient presented with massive thoraco-abdominal pain and severe dyspnea. At the time of admission, the patient was diagnosed with rupture of the diaphragm and developed cardiogenic shock. Intraoperatively there was a 4 cm diameter large rupture of the diaphragm with enterothorax (transverse colon, stomach, spleen, parts of the jejunum). Avulsion of the mesenteric arteries made a segmental resection of the jejunum together with the spleen necessary. A jejuno-jejunostomy was performed and organs were replaced into the abdomen. The rupture of the diaphragm underwent primary closure with non-resorbable suture material. The patient has shown an uneventful post-operative course, fully recovered and was discharged on day 11 after surgery. CONCLUSION: Covid 19 is a disease that is known to have various effects on different organs. The diaphragm is only paid heed in case of dysfunction. Also in the setting of Covid 19 it is not known as prominent effector organ. Nevertheless its affection by coughing caused by Covid 19 can lead to life threatening complications.

Retroperitoneal Haematoma - Still a Medical Challenge for Abdominal Trauma.

Introduction: The study is presenting a personal experience of a Trauma Centre Level I and is try to conclude on optimal medical attitude for patients with retroperitoneal hematoma, still a controversial topic for traumatologists. Material and Method: A retrospective analysis of 22 cases of post-traumatic retroperitoneal hematoma admitted on Bucharest Emergency Hospital between September 2018 August 2021 (including time of Covid-19 pandemic), is presented Results: The patients (males predominance, mean age 43, mean ISS of 23), benefited of nonoperative management on admission for 10 cases (45%) with a failure rate of 4/10 due to recurrent bleeding from spleen injuries and continuous bleeding from mesenteric vessels lesions. CT scan (73% - 16 cases) within 1 hour from the admission and emergency surgery were necessary for 12 cases (55%). 2 patients benefited of angioembolization on admission. Conservative attitude for retroperitoneal hematoma was adopted for 72% cases. Over-all mortality: 18% (4 patients, mean ISS of 36), among 82% polytrauma cases. Conclusions: Algorithm of treatment is adapted to every case of retroperitoneal hematoma but the following sequences are mandatory: rapid transportation to Trauma Centre Level I with medical help, correct resuscitation, immediate relevant imagistic (CT scan), emergency surgery prior to angioembolization (for hemodynamic instable patients) or after it, ICU stabilization of the patient and then definitive repair of the injuries. Despite all, mortality remains high.

Predicting Acute Respiratory Distress Syndrome in Severe Blunt Trauma: The Utility of Interleukin-18.

Background: In trauma, direct pulmonary injury and innate immune response activation primes the lungs for acute respiratory distress syndrome (ARDS). The inflammasome-dependent release of interleukin-18 (IL-18) was recently identified as a key mediator in ARDS pathogenesis, leading us to hypothesize that plasma IL-18 is a diagnostic predictor of ARDS in severe blunt trauma. Patients and Methods: Secondary analysis of the Inflammation and Host Response to Injury database was performed on plasma cytokines collected within 12 hours of severe blunt trauma. Trauma-related cytokines, including IL-18, were compared between patients with and without ARDS and were evaluated for association with ARDS using regression analysis. Threshold cytokine concentrations predictive of ARDS were determined using receiver-operating curve (ROC) analysis. Results: Cytokine analysis of patients without ARDS patients (n = 61) compared with patients with ARDS (n = 19) demonstrated elevated plasma IL-18 concentration in ARDS and IL-18 remained correlated with ARDS on logistic regression after confounder adjustment (p = 0.008). Additionally, ROC analysis revealed IL-18 as a strong ARDS predictor (area under the curve [AUC] = 0.83), with a threshold IL-18 value of 170 pg/mL (Youden index, 0.3). Unlike in patients without ARDS, elevated IL-18 persisted in patients with ARDS during the acute injury phase (p ≤ 0.02). Other trauma-related cytokines did not correlate with ARDS. Conclusions: In severe blunt trauma, IL-18 is a robust predictor of ARDS and remains elevated throughout the acute injury phase. These findings support the use of IL-18 as a key ARDS biomarker, promoting early identification of trauma patients at greater risk of developing ARDS. Timely recognition of ARDS and implementation of advantageous supportive care practices may reduce trauma-related ARDS morbidity and costs.