Periportal tracking in pediatric blunt abdominal trauma. Correlation with liver enzymes and liver injury.

This is a retrospective study of the computed tomography (CT) examinations and medical records of 243 consecutive pediatric patients sent for CT studies after blunt abdominal trauma. The purpose of the study was to determine the frequency and significance of periportal tracking identified by CT, and correlate this finding with liver enzyme levels and liver injury. Periportal tracking (PPT) was divided into four grades (0-3) depending upon the distribution of decreased attenuation adjacent to the portal vessels. Circumferential PPT extending to the periphery of the liver (grade 3) was found in 20/243 children. They had a higher incidence of liver parenchymal injury seen on CT 20% versus 0.5% in combined PPT grades 0-2. Sixteen children with grade 3 PPT and no liver injury had significantly elevated liver enzymes as compared to children with combined 0-2 grade PPT. Eleven of the 20 children with grade 3 PPT had no other CT evidence of intraabdominal injury and none of these patients developed intraabdominal hemorrhage. Thus, grade 3 periportal tracking as an isolated abnormality did not indicate a clinically significant liver injury in any patient.

A new method to obtain a tissue diagnosis of proximal bile duct tumors.

Klatskin tumors often pose a challenge for diagnosis and treatment. Most of these neoplasms are diagnosed clinically because of the difficulty in obtaining tissue that will provide histologic proof of the disease. When a non-operative course is sought, exhaustive attempts should be made to obtain a tissue diagnosis because of the potential for a false-positive clinical diagnosis. We describe a new way to obtain tissue for diagnosis by placing a laparoscopic choledochoscope through a percutaneous transhepatic cholangiogram track, thus allowing the tumor to be directly visualized and biopsied.

Laparoscopic injection of fibrin glue to arrest intraparenchymal abdominal hemorrhage: an experimental study.

The laparoscope offers a novel avenue for the diagnosis of intra-abdominal injury and the use of fibrin glue (FG) as a treatment for hemorrhage in trauma patients. This study was undertaken to assess the practicality and effectiveness of FG injection under laparoscopic direction to arrest hemorrhage in solid viscera. Twenty dogs were randomized into a control group (CG) and a treatment group (TG). All animals underwent laparotomy to surgically induce uniform injuries to the hepatic and splenic parenchyma. The TG animals (n = 12) were allowed to hemorrhage for 30 minutes. The injuries were then visualized and FG injected intraparenchymally under laparoscopic direction. The average duration of the procedure was 25 minutes (range, 15-50). No hemostatic interventions were performed on the CG animals (n = 8). Mortality in the CG was 63% (5 of 8); there were no deaths in TG animals prior to sacrifice. Necropsy of TG animals revealed progressively healing hepatic and splenic injuries with no gross evidence of pulmonary FG emboli, intraparenchymal microemboli, or increased adhesion formation. No other complications were noted. This study demonstrates that hemorrhage from the liver and spleen can be successfully controlled using the laparoscope to direct the intraparenchymal injection of FG. In this experimental model, the procedure can be performed expeditiously. It is associated with reduction of mortality to zero when compared with controls. No complications associated with laparoscopy or FG injection were recognized. This technique may have potential for application in the management of stable patients who manifest evidence of intraperitoneal hemorrhage as a result of solid organ injury.

Necrotizing infections of the perineum.

During a 6-year period, 10 patients were treated for severe necrotizing infections of the perineum (Fournier's gangrene) at the Edward Hines Veterans Administration Hospital (Hines, Ill). All were male, and their average age was 60 years. When known, duration of symptoms was 2 to 5 days. Prodromal signs such as edema, erythema, and pain frequently developed into rapidly spreading, full-thickness cutaneous gangrene in less than 24 hours. All patients had significant concomitant disease; 60% were diabetic. All patients had expedient and aggressive initial debridement, usually within 24 hours of presentation to the surgical service. Each patient had a "second-look" debridement within 1 or 2 days. Debridement was done an average of 2.6 times per patient. The cause of the infection was noted in seven patients--five with perirectal abscess and two with urethral trauma. Suprapubic catheters were placed in both patients with urethral trauma. Diverting colostomy was done on two patients who had perirectal abscess as a nidus; eight patients were treated without colostomy. Polymicrobial bacteriologic flora were found in all patients, with a predominance of Escherichia coli, Bacteroides sp, and staphylococci. Broad spectrum antibiotics and early nutritional supplementation were given. Hospital stay averaged 4 weeks (range, 3 to 12 weeks). One patient died (mortality of 10%). Successful management of these patients requires expedient diagnosis, aggressive nutritional supplementation, and early and repeated debridement as clinically indicated. We have not found diverting colostomy to be a necessary part of the management of these patients even when the nidus is perirectal.

Emergency cricothyroidotomy in trauma victims.

The first dictum of trauma care is to establish an airway. Infrequently endotracheal intubation is unsuccessful or contraindicated, and a surgical airway is required. We reviewed 30 emergency cricothyroidotomies among 8320 admissions over a 36-month period at a level I trauma center. Twenty cricothyroidotomies were performed in the emergency room by Trauma Service personnel and 10 during prehospital care by flight nurses. Cricothyroidotomy was the first airway control maneuver performed in 7 patients and 23 cricothyroidotomies were performed after attempts at oral intubation failed. No major complications were identified. Minor complications identified in the hospital included minimal subglottic stenosis (2), local wound infection (1), and nonthreatening hemorrhage (1). Fifteen patients were long-term survivors. We conclude that emergency cricothyroidotomy is a safe and rapid means of obtaining an airway when endotracheal intubation fails or is contraindicated.

The role of diagnostic laparoscopy in the management of trauma patients: a preliminary assessment.

This study evaluated the role and advantages of diagnostic laparoscopy (DL) compared with diagnostic peritoneal lavage (DPL) in 75 trauma patients who were prospectively studied with DL followed by DPL. Of these, 59 patients had blunt injuries and 16 stab wounds. Seventy patients (93%) had the procedures performed in the emergency department (ED); 41 (59%) of these were awake and under local anesthesia. Forty-two patients had negative DPL and DL results with no subsequent sequelae. Twenty-three patients had negative DPL results and abnormal DL results. Of these, 20 were managed nonsurgically, and three (DPL < 10,000 RBC) underwent surgery based solely on DL findings of diaphragmatic lacerations from stab wounds. These were repaired. All 23 had an uneventful course. Three patients had positive DPL and insignificant DL findings. Laparotomy and DL findings correlated. A splenectomy for iatrogenic injury unrelated to DL and two nontherapeutic laparotomies were performed. Seven patients demonstrated both positive DPL and significant DL findings, and all had therapeutic laparotomies. Management based on DL rather than DPL would potentially have improved care in 8% of cases (6 of 75). Reliance on DL improved care in 19% (3 of 16) of patients with stab wounds and possibly could have in 3% (2 of 59) of those with blunt injuries. Management using DL would have potentially improved care in 30% (3 of 10) of patients with positive DPL findings and 5% (3 of 65) with negative DPL findings. Diagnostic laparoscopy can be performed safely in stable patients under local anesthesia in the ED. It offers no advantage over DPL as a primary assessment tool in blunt trauma. It does have advantages in the management of stab wounds. Diagnostic laparoscopy has a role in redefining DPL criteria for laparotomy and, in selected patients, as an adjunct to DPL, allowing further diagnosis and potentially the treatment of injuries without laparotomy.

Routine pelvic x-ray studies in awake blunt trauma patients: a sensible policy?

To evaluate the usefulness of routine pelvic x-ray films in the resuscitation of blunt trauma victims, 1395 patients were prospectively evaluated over a 13-month period. Of these, 810 (58%) were awake with Glasgow Coma Scale scores greater than or equal to 13 and were enrolled into the study. A history, with directed questions regarding pelvic pain, a clinical examination of the pelvis, and an anterior-posterior pelvic x-ray film (APPX) were obtained for each patient. Thirty-nine patients (5%) had fractures identified on the x-ray films. Of these patients with radiographically identified fractures, 34 (87%) complained of pain and had positive results on clinical examination, two (5%) either complained of pain or had positive results on examination and three (8%) had neither complaint of pain nor positive examination results. Of the 771 patients without fractures 743 (96%) lacked pain complaints or positive examination results. The likelihood of fracture was greatest in patients with complaints of pain and positive examination results (65%) followed by patients with either complaint of pain or positive examination results (16%). Only three (0.4%) of the 743 patients having no complaints of pain and a negative clinical examination had fractures diagnosed roentgenographically. These were minor fractures that did not affect the clinical course. Total charges incurred to diagnose pelvic fractures in this low-yield patient group were $88,028. We conclude that the practice of obtaining a screening APPX is not necessary or cost-effective in the management of awake blunt trauma patients who do not complain of pain and who have normal pelvic physical examination results.

Transoral crossbow injury to the cervical spine: an unusual case of penetrating cervical spine injury.

The complexity of missile injuries to the cervical spine has increased as the technology that causes these injuries has become more sophisticated. Management requires adaptation of conventional neurosurgical approaches to the cervical spine in an effort to limit neurological deficit and establish stability. We report an unusual case of a 19-year-old man who suffered transoral penetration of the cervical spine by an arrow released by a crossbow at close range.

Circulating concentrations of porcine ileal peptide but not hexosaminidase are elevated following 1 hr of mesenteric ischemia.

Porcine Ileal Peptide (PIP) is located in the mucosa of the small bowel. We hypothesized that PIP may be useful as a marker for early intestinal ischemia or other acute processes of the mucosa. To test this hypothesis we developed a model of acute reversible intestinal ischemia in the pig. Following isolation of a 100-cm segment of ileum on a vascular pedicle baseline, serum and tissue samples were obtained. The vessels were then occluded for 60 min and the segment was reperfused. Serial serum samples were taken and analyzed for PIP and hexosaminidase (HEX). HEX enzyme activity in serum is known to be elevated in animals having intestinal necrosis. The Student t test for paired data was used. In preliminary studies we found that circulating HEX activity became elevated following 3 to 4 hr of vessel occlusion followed by reperfusion. In the current experiments, following 1 hr of ischemia, PIP rose significantly in the peripheral circulation, being 153.8 +/- 76.8, 909.0 +/- 150.4, and 898.3 +/- 128.1 ng/ml (P less than 0.001) at 0, 60, and 360 min after reperfusion of the segment. HEX on the other hand did not change significantly throughout the experiment, having been 766.0 +/- 28.1, 752.0 +/- 71.3, and 780.1 +/- 53.7 nM/liter (ns) at 0, 60, and 360 min following reperfusion of the segment. Histology demonstrated some clubbing, shortening and fracturing of villi with thinning of the tips of the villi in many cases. Immunospecific staining for PIP was present along the intact borders of the villi.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal cranial and craniocervical masses: ultrasound characteristics and differential diagnosis.

Ultrasound is assuming an essential role in the detection of fetal cranial and spinal anomalies. Illustrated in this article is the sonographic appearance of cranial abnormalities wherein the diagnosis of encephalocele is clear cut because the anatomic defect of the neural tube is visualized. Additionally presented is a variety of cranial and craniocervical cystic masses, including meningocele, wherein the anatomic defect of the neural tube is not apparent and the diagnosis is reached by careful attention to the specific ultrasonic characteristics of each mass.