ABSTRACT
BACKGROUND: Since the 1980s, there have been isolated reports of a toxic shock syndrome associated with Clostridium sordellii necrotizing subcutaneous infections during the puerperium. Relatively localized fascial and muscle necrosis is noted at the surgical incision sites. However, circulating toxins produce marked edema, resulting in shock and cardiovascular collapse. Despite aggressive surgical and supportive therapy, all postpartum cases thus far have been fatal. CASE: A 24-year-old primipara developed an episiotomy infection which progressed to involve the underlying fascia and muscle. Despite early and adequate debridement of the devitalized tissue, she developed anasarca, marked leukocytosis, refractory hypotension, hypothermia, and a persistent coagulopathy, and expired on postpartum day 5. The cultures from the excised tissue grew C. sordellii All blood cultures were negative. CONCLUSION: Treatment modalities aimed solely at the eradication of the microbe and removal of necrotic tissue, although essential components of therapy, have proved inadequate. Future efforts should be directed toward neutralization or elimination of the circulating exotoxins responsible for the systemic shock.
ABSTRACT
Nonoperative management of blunt hepatic injury (BHI) has become more widely accepted. A prospective trial was undertaken to test the belief that clinical state could identify the patients with BHI confirmed by computed tomography (CT) who could be safely managed without a surgical operation. Patients were excluded from nonoperative management only if they manifested hemodynamic instability, the presence or suspicion of any other injury requiring laparotomy, or would be unavailable for controlled monitoring. Of 60 patients treated for BHI, 30 were managed nonoperatively. The 30 who had laparotomies served as a comparative group. The groups were statistically similar in age, sex, and Injury Severity Score (ISS). The group managed nonoperatively had significantly more severe BHI. There were no deaths or delayed laparotomies in the nonoperative management group. The groups had similar ICU and total hospital stays when analyzed as independent variables or with control for BHI grade and ISS. Transfusion requirements were significantly lower for the nonoperative management group when analyzed independently or when controlled for BHI grade, ISS, and the number of non-abdominal injuries. Nineteen (63%) patients managed nonoperatively were followed until their CT scans showed complete resolution. None had complications. We conclude that nonoperative management of BHI is a safe and effective technique applicable to hemodynamically stable patients who lack other indications for laparotomy and who can be adequately monitored.
