Delayed small bowel perforation following blunt abdominal trauma: A case report and review of the literature.

We report a case of delayed presentation of a small bowel perforation following blunt abdominal trauma (BAT). An initial computed tomography (CT) scan revealed that the patient (a 32-year-old man) had a mesenteric hematoma, which was managed conservatively. Four weeks later, he returned to the hospital complaining of abdominal pain. A CT scan of the abdomen showed a thickened loop of the small bowel adjacent to the mesenteric hematoma at the level of the ileum. He was discharged home, but re-presented with acute abdomen 6 weeks post-trauma. An exploratory laparotomy was performed, which showed a perforated thickened loop of the ileum forming a phlegmon in the lower abdomen. In the English medical literature, only eight other reports of delayed post-traumatic presentation of ileal/jejunal perforation following BAT have been reported. We propose that post-traumatic intestinal perforation be considered in the differential diagnosis even in patients who experience a delayed small bowel perforation following BAT.

Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature.

INTRODUCTION: Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient's primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality. PRESENTATION OF CASE: A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient's TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting. DISCUSSION: TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success. CONCLUSION: The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.

Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis.

INTRODUCTION: Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax. METHODS: We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax. RESULTS: We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used. CONCLUSIONS: Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.

Anatomic guide and sonography for surgical repair of leg muscle lacerations.

BACKGROUND: There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg. MATERIALS AND METHODS: The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection. RESULTS: There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg. CONCLUSION: The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.

A Patient With Blunt Trauma and Cardiac Arrest Arriving Pulseless at the Emergency Department; is that Enough Reason to Stop Resuscitation? Review of Literature and Case Report.

The decision to stop or continue resuscitation in a patient with blunt trauma and cardiac arrest arriving pulseless to the hospital has always been controversial. While many authors still believe that it is a futile effort, with no chance of success for complete neurological recovery, some recent reports have challenged the idea. Here we report complete recovery of a severely injured patient following a motor vehicle accident who lost vital signs completely before arrival at our trauma center. No cardiac motion was detected on ultrasound examination on arrival. Emergency department thoracotomy, open cardiac massage, massive blood transfusion, damage control laparotomy with abdominal and pelvic packing, followed by angio-embolization of pelvic bleeding, and staged abdominal exploration were performed. This case is an example showing that resuscitation of patients with blunt trauma and cardiac arrest arriving pulseless to the hospital is not always futile.

Intra-abdominal hypertension causes disruption of the blood-brain barrier in mice, which is increased with added severe head trauma.

BACKGROUND: Although the individual effect of head trauma and intra-abdominal hypertension (IAH) causing blood-brain barrier (BBB) disruption has been studied separately, their combined effect on the integrity of BBB has not been investigated. This study examines the effects of IAH and head trauma, individually and in combination, on the permeability of the BBB in mice. METHODS: Male CD-1 mice weighing 30 to 38 g were used. Control mice were anesthetized for 4 hours. The mice in the experimental group underwent the following: (1) IAH 4 hours, (2) head trauma, and (3) combined head trauma and IAH 4 hours. IAH was induced by intraperitoneal infusion of mineral oil to a pressure of 20 mm Hg. Head trauma was induced using weight drop technique. BBB permeability was quantified using the Evans blue dye extravasation method. RESULTS: BBB permeability was higher in the mice with IAH 4 hours compared with the control group (p < 0.05), higher in the mice with head trauma compared with the control group (p < 0.05), and significantly higher than the IAH and the control groups in the mice with combined IAH 4 hours and head trauma (both p < 0.05). CONCLUSION: The disruption of BBB in mice is produced by IAH and is increased with severe head trauma.

Nonoperative management of contained retrohepatic caval injury.

Traumatic inferior vena cava (IVC) injuries are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. Here, we report a case of a young female with a single gunshot wound to her abdomen, who presented to our level 1 trauma center 10 minutes after injury and was hemodynamically stable. A computed tomographic scan revealed a large liver laceration with a trajectory through the liver and the IVC. The IVC was surrounded by a moderate amount of fluid, consistent with a contained retroperitoneal hematoma. We discuss the outcome of nonoperative management of this patient along with a review of the literature.

Intra-abdominal hypertension causes reversible blood-brain barrier disruption.

BACKGROUND: Previous studies have shown that intra-abdominal hypertension (IAH) has detrimental effects on organ function and is associated with significantly increased morbidity and mortality. IAH has also been shown to increase intracranial pressure. The exact mechanism is not known. This study tests the effect of an acute increase in intra-abdominal pressure on the permeability of the blood-brain barrier (BBB) in mice. METHODS: Male CD-1 mice weighing 30 g to 38 g were used. Mice in experimental groups underwent either 4 hours of IAH or 4 hours of IAH followed by 1 hour of decompression (DC). A set of control mice were anesthetized for either 4 hours or 5 hours. Femoral artery cannulation was used for blood pressure monitoring. IAH was induced by intraperitoneal infusion of mineral oil to a pressure of 20 mm Hg. DC was performed through an incision in the anterior abdominal wall. BBB integrity was determined by extravasation of 2% Evans blue (EB) dye administered through the femoral vein 1 hour before the mice were killed. BBB permeability was quantified by the EB extravasation method. RESULTS: EB content in brain tissue was higher in the IAH 4-hour group (n = 12) compared with their control group (n = 4; p < 0.05), indicating increased permeability of BBB. In the IAH 4-hour + DC 1-hour group (n = 6), EB content in brain tissue was not significantly higher than their respective control group (n = 6). CONCLUSION: IAH of 20 mm Hg in mice for 4 hours caused increased BBB permeability. This endothelial barrier dysfunction is reversed by abdominal DC.

Unusual late occurrence of bowel obstruction following blunt abdominal trauma.

We report a case of late occurrence of small bowel obstruction due to stricture resulting from blunt abdominal trauma. On initial computed tomography (CT) scan, the patient had a mesenteric hematoma, which was managed conservatively. Approximately two weeks later, he complained of worsening abdominal pain and developed clinical signs of bowel obstruction. A repeat enhanced CT scan showed a stenotic loop of distal ileum adjacent to a large mesenteric mass. The loop was resected. We propose that post-traumatic intestinal stenosis be considered in the differential diagnosis in patients who have experienced blunt abdominal trauma and present later with clinical signs of bowel obstruction.