Bronchoperitoneal and Enterocutaneous Fistula Development Following a Colorectal Anastomosis Leak.

Bronchoperitoneal fistulas are rare but serious pathologies that pose numerous treatment challenges to physicians. There is usually a delay in diagnosis, and treatment recommendations are mainly derived from case reports. Here, we present an interesting case of a patient who developed a left bronchoperitoneal fistula and two subsequent enterocutaneous fistulas resulting from a massive intra-abdominal phlegmon eroding through the left diaphragm. The patient experienced numerous medical complications during his hospital stay and required multiple operations. However, 18 months after his initial post-operative complication, the bronchoperitoneal fistula has healed, and the patient has undergone successful intestinal reconstruction. This case highlights multiple uncommon disease processes and the treatment strategies used.

Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.

BACKGROUND: Increased accessibility and rapidity of computed tomography (CT) have led to increased use and radiation exposure to pediatric trauma patients. The thyroid is radiosensitive and therefore at risk for developing malignancy from radiation exposure during cervical spine CT. This analysis aimed to determine which preelementary trauma patients warrant cervical spine CT by defining incidence and clinical characteristics of preelementary cervical spine injury. METHODS: This was a retrospective review of pre-elementary trauma patients from 1998 to 2010 with cervical spine injury admitted to a Level I trauma center. Patients were identified from the trauma registry using DRG International Classification of Diseases-9th Rev. codes and reviewed for demographics, mechanism of injury, clinical presentation, injury location, injury type, treatment, and outcome. RESULTS: A total of 2,972 preelementary trauma patients were identified. Twenty-two (0.74%) had confirmed cervical spine injuries. Eleven (50%) were boys, and the mean (SD) age was 3 (1.7) years. The most common mechanism of injury was motor vehicle collision (n = 16, 73%). The majority (59%) were in extremis, and 12 (55%) arrived intubated. The median Glasgow Coma Scale (GCS) score was 3 (interquartile range, 3-10); the median Injury Severity Score (ISS) was 33 (interquartile range, 17-56). Nineteen injuries (76%) were at the level of C4 level and higher. The mortality rate was 50%. All patients had clinical findings suggestive of or diagnostic for cervical spine injury; 18 (82%) had abnormal neurologic examination result, 2 (9%) had torticollis, and 2 (9%) had neck pain. CONCLUSION: The incidence of cervical spine injury in preelementary patients was consistent with previous reports. Missing a cervical spine injury in asymptomatic preelementary patients is extremely low. Reserving cervical spine CT to symptomatic preelementary patients would decrease unnecessary radiation exposure to the thyroid. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Natural history and clinical implications of nondepressed skull fracture in young children.

BACKGROUND: Head injury is the most common cause of neurologic disability and mortality in children. Previous studies have demonstrated that depressed skull fractures (SFs) represent approximately one quarter of all SFs in children and approximately 10% percent of hospital admissions after head injury. We hypothesized that nondepressed SFs (NDSFs) in children are not associated with adverse neurologic outcomes. METHODS: Medical records were reviewed for all children 5 years or younger with SFs who presented to our Level I trauma center during a 4-year period. Data collected included patient demographics, Glasgow Coma Scale (GCS) score at admission, level of consciousness at the time of injury, type of SF (depressed SF vs. NDSF), magnitude of the SF depression, evidence of neurologic deficit, and the requirement for neurosurgical intervention. RESULTS: We evaluated 1,546 injured young children during the study period. From this cohort, 563 had isolated head injury, and 223 of them had SF. Of the SF group, 163 (73%) had NDSFs, of whom 128 (78%) presented with a GCS score of 15. None of the NDSF patients with a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Of the remaining 35 patients with NDSF and GCS score less than 15, 7 (20%) had a temporary neurologic deficit that resolved before discharge, 4 (11%) developed a persistent neurologic deficit, and 2 died (6%). CONCLUSION: Children 5 years or younger with NDSFs and a normal neurologic examination result at admission do not develop neurologic deterioration. LEVEL OF EVIDENCE: Epidemiological study, level III.

Estimating thyroid dose in pediatric CT exams from surface dose measurement.

The purpose of this study was to investigate the possibility of estimating pediatric thyroid doses from CT using surface neck doses. Optically stimulated luminescence dosimeters were used to measure the neck surface dose of 25 children ranging in ages between one and three years old. The neck circumference for each child was measured. The relationship between obtained surface doses and thyroid dose was studied using acrylic phantoms of various sizes and with holes of different depths. The ratios of hole-to-surface doses were used to convert patients' surface dose to thyroid dose. ImPACT software was utilized to calculate thyroid dose after applying the appropriate age correction factors. A paired t-test was performed to compare thyroid doses from our approach and ImPACT. The ratio of thyroid to surface dose was found to be 1.1. Thyroid doses ranged from 20 to 80 mGy. Comparison showed no statistical significance (p = 0.18). In addition, the average of surface dose variation along the z-axis in helical scans was studied and found to range between 5% (in 10 cm diameter phantom/24 mm collimation/pitch 1.0) and 8% (in 16 cm diameter phantom/12 mm collimation/pitch 0.7). We conclude that surface dose is an acceptable predictor for pediatric thyroid dose from CT. The uncertainty due to surface dose variability may be reduced if narrower collimation is used with a pitch factor close to 1.0. Also, the results did not show any effect of thyroid depth on the measured dose.

Pediatric radiation exposure during the initial evaluation for blunt trauma.

BACKGROUND: Increased utilization of computed tomography (CT) scans for evaluation of blunt trauma patients has resulted in increased doses of radiation to patients. Radiation dose is relatively amplified in children secondary to body size, and children are more susceptible to long-term carcinogenic effects of radiation. Our aim was to measure radiation dose received in pediatric blunt trauma patients during initial CT evaluation and to determine whether doses exceed doses historically correlated with an increased risk of thyroid cancer. METHODS: A prospective cohort study of patients aged 0 years to 17 years was conducted over 6 months. Dosimeters were placed on the neck, chest, and groin before CT scanning to measure surface radiation. Patient measurements and scanning parameters were collected prospectively along with diagnostic findings on CT imaging. Cumulative effective whole body dose and organ doses were calculated. RESULTS: The mean number of scans per patient was 3.1 ± 1.3. Mean whole body effective dose was 17.43 mSv. Mean organ doses were thyroid 32.18 mGy, breast 10.89 mGy, and gonads 13.15 mGy. Patients with selective CT scanning defined as ≤2 scans had a statistically significant decrease in radiation dose compared with patients with >2 scans. CONCLUSIONS: Thyroid doses in 71% of study patients fell within the dose range historically correlated with an increased risk of thyroid cancer and whole body effective doses fell within the range of historical doses correlated with an increased risk of all solid cancers and leukemia. Selective scanning of body areas as compared with whole body scanning results in a statistically significant decrease in all doses.

A comparison of the hemoglobin-based oxygen carrier HBOC-201 to other low-volume resuscitation fluids in a model of controlled hemorrhagic shock.

BACKGROUND: The ideal resuscitation fluid for military applications would be effective at low volumes, thereby reducing logistical constraints. We have previously shown that the bovine hemoglobin-based oxygen carrier HBOC-201 is an effective low-volume resuscitation fluid. The goal of this experiment was to evaluate the effectiveness of HBOC-201 in comparison with other low-volume resuscitation fluids in a swine model of controlled hemorrhagic shock. METHODS: Forty-two immature female Yorkshire swine (55-70 kg) were divided into seven groups of six. Animals were hemorrhaged to a mean arterial pressure of 30 mm Hg. After 45 minutes, animals were resuscitated to a mean arterial pressure of 60 mm Hg with one of the following agents: hypertonic saline 7.5% (HTS), hypertonic saline 7.5%/Dextran-70 6% (HSD), pentastarch 6%, hetastarch 6%, or HBOC-201. Lactated Ringer's (LR) solution was used as a standard resuscitation control. Another group of animals received no resuscitation. Resuscitation was continued for 4 hours. Hemodynamic variables and oxygen consumption were measured continuously. Arterial and mixed venous blood gases and serum lactate levels were measured at intervals throughout the experiment. Data were analyzed using analysis of variance with Tukey's post hoc test when appropriate. Significance was defined as p < 0.05. RESULTS: Five of six animals in the no-resuscitation control group, six of six in the HTS group, and one animal in the HSD group died before completion of the study. All other animals survived to completion. Animals receiving resuscitation with HBOC-201 had significantly lower cardiac output, mixed venous oxygen saturation levels, and urinary output throughout the resuscitation period; however, there were no differences with regard to lactate, base excess, or oxygen consumption. Animals receiving HBOC-201 required significantly less fluid than any other group. CONCLUSION: In this model, hypotensive resuscitation with HBOC-201 restores tissue oxygenation and reverses anaerobic metabolism at significantly lower volumes when compared with HTS, HSD, pentastarch, or hetastarch solutions. These data suggest that HBOC-201 would be an effective primary resuscitation fluid for far-forward military or rural trauma settings where logistic constraints and prolonged transport times are common. However, when HBOC-201 is administered as a primary resuscitation fluid in hypotensive protocols, common clinical markers for determining adequacy of resuscitation may not be useful.

The effect of the bovine hemoglobin oxygen therapeutic HBOC-201 on human neutrophil activation in vitro.

BACKGROUND: We previously demonstrated that HBOC-201 is an efficient resuscitation fluid. However, little is known about its immunomodulatory effects. The goal of this study was to investigate human neutrophil activation after exposure to HBOC-201 and other low-volume resuscitation fluids. METHODS: Whole blood from 10 healthy volunteers was serially diluted with HBOC-201, 7.5% hypertonic saline (HTS), 7.5% hypertonic saline-6% dextran 70 (HSD), Hextend, or PentaLyte. After an incubation period, samples were analyzed for oxidative burst and CD11b expression using flow cytometry. RESULTS: Increases in both CD11b and oxidative burst activity were noted in samples diluted with HBOC-201, Hextend, PentaLyte, and lactated Ringer's solution. Samples maximally diluted with HBOC-201 demonstrated increased CD11b expression when compared with lactated Ringer's solution and Hextend (196.11% vs. 22.68% and 33.97%; p = 0.018 and p = 0.033). CONCLUSION: Although differences were noted only at the highest dilutions, further studies investigating the effects of HBOC-201 are warranted.

The polymerized bovine hemoglobin-based oxygen-carrying solution (HBOC-201) is not toxic to neural cells in culture.

BACKGROUND: Recent data suggest that a neurotoxic effect of blood or its components may contribute to secondary neural cell dysfunction. This study investigated the effects of HBOC-201 (Hemopure) and purified human hemoglobin (hHgb) on rat fetal neural cell culture. METHODS: Neural cell cultures were exposed to HBOC-201 and hHgb (0.02, 0.2, 2.0, and 6.5 g/dL) for 24 hours, and then analyzed for proliferation, metabolism, and neurolysis. RESULTS: Cultures exposed to HBOC-201 maintained levels of proliferation and metabolism similar to controls while demonstrating no cellular lysis. However, cultures exposed to hHgb demonstrated decreased proliferation after exposure to 0.2, 2.0, and 6.5 g/dL hHgb (14,252.14, 3,221.89, and 343.12 vs. 19,509.53; p< 0.05) when compared with controls. In addition, cultures exposed to hHgb demonstrated decreased metabolic activity and increased cell lysis when compared with controls (p < 0.05). CONCLUSION: Cultures exposed to HBOC-201 displayed sustained metabolic activity and proliferation, and demonstrated no neurolysis, suggesting that HBOC-201 does not display the toxic characteristics of hHgb.