Efficacy of past, present, and future fluid strategies in an improved large animal model of non-compressible intra-abdominal hemorrhage.

BACKGROUND: Noncompressible hemorrhage is a leading cause of potentially survivable combat death, with the vast majority of such deaths occurring in the out-of-hospital environment. While large animal models of this process are important for device and therapeutic development, clinical practice has changed over time and past models must follow suit. Developed in conjunction with regulatory feedback, this study presents a modernized, out-of-hospital, noncompressible hemorrhage model, in conjunction with a randomized study of past, present, and future fluid options following a hypotensive resuscitation protocol consistent with current clinical practice. METHODS: We performed a randomized controlled experiment comparing three fluid resuscitation options in Yorkshire swine. Baseline data from animals of same size from previous experiments were analyzed (n = 70), and mean systolic blood pressure was determined, with a permissive hypotension resuscitation target defined as a 25% decrease from normal (67 mm Hg). After animal preparation, a grade IV to V liver laceration was induced. Animals bled freely for a 10-minute "time-to-responder" period, after which resuscitation occurred with randomized fluid in boluses to the goal target: 6% hetastarch in lactated electrolyte injection (HEX), normal saline (NS), or fresh whole blood (FWB). Animals were monitored for a total simulated "delay to definitive care" period of 2 hours postinjury. RESULTS: At the end of the 2-hour study period, 8.3% (1 of 12 swine) of the HEX group, 50% (6 of 12 swine) of the NS group, and 75% (9 of 12 swine) of the FWB had survived (p = 0.006), with Holm-Sidak pairwise comparisons showing a significant difference between HEX and FWB and (p = 0.005). Fresh whole blood had significantly higher systemic vascular resistance and hemoglobin levels compared with other groups (p = 0.003 and p = 0.001, respectively). CONCLUSION: Survival data support the movement away from HEX toward NS and, preferably, FWB in clinical practice and translational animal modeling. The presented model allows for future research including basic science, as well as translational studies of novel diagnostics, therapeutics, and devices.

A novel model of highly lethal uncontrolled torso hemorrhage in swine.

INTRODUCTION: A reproducible, lethal noncompressible torso hemorrhage model is important to civilian and military trauma research. Current large animal models balancing clinical applicability with standardization and internal validity. As such, large animal models of trauma vary widely in the surgical literature, limiting comparisons. Our aim was to create and validate a porcine model of uncontrolled hemorrhage that maximizes reproducibility and standardization. METHODS: Seven Yorkshire-cross swine were anesthetized, instrumented, and splenectomized. A simple liver tourniquet was applied before injury to prevent unregulated hemorrhage while creating a traumatic amputation of 30% of the liver. Release of the tourniquet and rapid abdominal closure following injury provided a standardized reference point for the onset and duration of uncontrolled hemorrhage. At the moment of death, the liver tourniquet was quickly reapplied to provide accurate quantification of intra-abdominal blood loss. Weight and volume of the resected and residual liver segments were measured. Hemodynamic parameters were recorded continuously throughout each experiment. RESULTS: This liver injury was rapidly and universally lethal (11.2 ± 4.9 min). The volume of hemorrhage (35.8% ± 6% of total blood volume) and severity of uncontrolled hemorrhage (100% of animals deteriorated to a sustained mean arterial pressure <35 mmHg for 5 min) were consistent across all animals. Use of the tourniquet effectively halted preprocedure and postprocedure blood loss allowing for accurate quantification of amount of hemorrhage over a defined period. In addition, the tourniquet facilitated the creation of a consistent liver resection weight (0.0043 ± 0.0003 liver resection weight: body weight) and as a percentage of total liver resection weight (27% ± 2.2%). CONCLUSIONS: This novel tourniquet-assisted noncompressible torso hemorrhage model creates a standardized, reproducible, highly lethal, and clinically applicable injury in swine. Use of the tourniquet allowed for consistent liver injury and precise control over hemorrhage. Recorded blood loss was similar across all animals. Improving reproducibility and standardization has the potential to offer improvements in large animal translational models of hemorrhage. LEVEL OF EVIDENCE: Level I.

Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rescue maneuver for unstable patients with noncompressible hemorrhage below the diaphragm. The efficacy of REBOA in the setting a major abdominal venous injury is unknown. Our objective was to examine the use of REBOA in a large animal model of major abdominal venous injury and characterize any impact on the hemodynamics, rate and volume of hemorrhage, and survival. METHODS: Ten swine (35-55 kg) underwent a controlled and validated hemorrhage and ischemia/reperfusion injury protocol to produce shock physiology. Animals were randomly assigned to a control arm (N = 5) or a treatment (REBOA) arm (N = 5). An injury was then created in the common iliac vein. Bleeding was allowed for 60 seconds and the balloon was then inflated in the REBOA arm. Hemodynamics were recorded for 45 minutes or until death. Blood loss was verified post-mortem and bleeding rate calculated. RESULTS: All animals demonstrated shock physiology at the time of randomization. There were no differences between control versus REBOA animals in baseline mean arterial pressure (42 vs. 50), pH (7.29 vs. 7.26), lactate (6.19 vs. 6.26), or INR (1.2 vs. 1.3, all p = NS). REBOA animals demonstrated immediate improvements in mean arterial pressure (50.6 vs. 97.2, p = 0.04). The mean survival time was 4.1 minutes for controls (100% died) versus 40.1 minutes for REBOA (p < 0.01). There was no difference in total blood loss (mean 630 mL for both). The rate of bleeding was significantly lower in the REBOA animals (control 197 mL/min vs. REBOA 14 mL/min, p = 0.02). CONCLUSION: In the setting of an abdominal venous injury, REBOA improved hemodynamics and lengthened survival time. Blood loss was similar between groups but the rate of bleeding was markedly decreased with REBOA. REBOA appears effective for central venous injuries and provides a sustained period of stabilization and window for surgical intervention.

Severe spontaneous hemoperitoneum in pregnancy may be linked to in vitro fertilization in patients with endometriosis: a systematic review.

OBJECTIVE: To evaluate existing evidence of a possible association in women with endometriosis between controlled ovarian hyperstimulation plus embryo transfer (COH-ET) and the occurrence of spontaneous hemoperitoneum in pregnancy (SHiP). DESIGN: Comprehensive review. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): An electronic literature search up to February 2016 was conducted using Scopus and PubMed. MAIN OUTCOME MEASURE(S): The role of COH-ET in SHiP. RESULT(S): Controlled ovarian hyperstimulation plus embryo transfer may increase the severity or incidence of the rare condition known as SHiP. An analysis of published cases shows that bleeding often occurs from multiple or diffuse sites, mainly situated in the posterior pelvic cavity, making it difficult to control without interfering with the pregnancy itself. Spontaneous hemoperitoneum in pregnancy is linked to adverse perinatal outcomes, including stillbirth, neonatal mortality, and very low or low birth weight. In 14 cases a biopsy of the bleeding site was obtained, and in all cases, even in the absence of visible endometriosis, decidualization was documented. At present, the relatively small number of cases published prevents firm conclusions, although they are highly suggestive of a link between COH-ET in women with endometriosis and the occurrence and seriousness of SHiP. CONCLUSION(S): Spontaneous hemoperitoneum in pregnancy is a rare but potentially fatal complication for the pregnant woman and her unborn child. In vitro fertilization in women with severe endometriosis may be a risk factor for SHiP.

Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid.

BACKGROUND: In our institution, the computed tomographic (CT) scan has largely replaced the ultrasound for the rapid detection of intraperitoneal free fluid (FF) and abdominal injuries in severely injured patients.We hypothesized that in major pelvic fracture patients, quantifying the size of FF on CT improves the predictive value for the need for abdominal hemorrhage control (AHC). METHODS: The CT scans of major pelvic fracture (pelvic ring disruption) patients (January 1, 2004, to June 31, 2012) were reviewed for the presence of FF (small, moderate, or large amount) and abdominal injuries. AHC was defined as requiring a surgical intervention for active abdominal bleeding or angiographic embolization for an abdominal arterial injury.Positive predictive value (PPV) and negative predictive value (NPV) (95% confidence interval [CI]) were calculated for all patients and in a subgroup of patients with a high risk for significant hemorrhage (base deficit ≥ 6 mEq/L). RESULTS: Overall, 160 patients were included in the study. Of the 62 FF patients, 26 required AHC (PPV, 42%, 95% CI, 30-55%). Of the 98 patients without FF, none required AHC (NPV, 100%; 95% CI, 95-100%). For a moderate-to-large amount of FF, the PPV and NPV in all patients were 81% (95% CI, 60-93%) and 96% (95% CI, 91-99%), respectively.In the subgroup of 49 high-risk patients (31%), 17 of 26 FF patients required AHC (PPV, 65%; 95% CI, 44-82%), and none of the 23 patients without FF required AHC (NPV, 100%; 95% CI, 82-100%). For a moderate-to-large amount, the PPV and NPV in high-risk patients were 93% (95% CI, 64-100%) and 89% (95% CI, 72-96%), respectively. CONCLUSION: In major pelvic fracture patients, the predictive value of FF on CT for the need for AHC is closely related to the amount present. A moderate-to-large amount of FF is highly predictive for the presence of abdominal bleeding that requires hemorrhage control. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

[Hemoperitoneum as a predictor of the traumatic process complications in the injured persons with severe combined trauma].

Multifactorial analysis was conducted in 48 injured persons, who had suffered combined abdominal organs trauma, trauma severity score according to the AIS-90 scale more than 25 points, and died. There were elaborated theoretical aspects of prognostication of the injured person's death timing. There was established, that while hemoperitoneum volume enhancement by 200 ml (critical level of hemoperitoneum is considered 682 ml) the death timing becomes accelerated by 1.2 h.

[The risk of death from splenic ruptures by polytrauma among children].

The retrospective analysis of polytrauma with lethal outcome in 105 children showed that splenic injury had 31.4% of children. It was twice more often than liver injury, though the hemoperitoneum volume by liver injury exceeds that by spleen trauma (846.1±753.8 ml vs. 311±270.3 ml; p<0.002). The risk of death of intraabdominal bleeding by the spleen rupture is considerably low (OR 0.16; 95% CI 0.019-1.34; p=0.04). Nevertheless, the hemothorax by the spleen injury was much more significant than hemoperitoneum (977±866.9 ml vs. 311±270.3 ml; p<0.0003). The risk of death of intrathoracic bleeding by the spleen rupture is 45 times higher than of intraabdominal. The degree of splenic injury poorly correlates with the traumatic mechanism and the hemoperitoneum volume. The chances of the immediate death is considerably low (OR 0.09; 95% CI 0.0096-0.84; p<0.017). The main reasons of death by polytrauma remain brain injury, hemorrhagic shock after injury of thoracic cavity and traumatic shock.

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: a level-one trauma-centre experience.

PURPOSE: This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography. METHODS: From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented. RESULTS: Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18-66) with 62.5% mean probability of survival (6.8-98.8%). The mean operating time for RPP was 23 mins (20-35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation. CONCLUSION: Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.

[The changes of intraabdominal pressure in patients with retroperitoneal bleeding].

The linear dependence of the intraabdominal pressure and the volume of retroperitoneal bleeding was revealed in 34 patients with the aortic aneurism rupture. In patients with the blunt abdominal trauma, treated conservatively and laparotomized (each group consisted of 26 patients), the intraabdominal pressure is higher in the operated group during the first day after the operation. The main factors of the intraabdominal hypertension seem to be shock and massive infusion and transfusion therapy.

Management of spontaneously ruptured hepatocellular carcinoma and hemoperitoneum manifested as acute abdomen in the emergency room.

BACKGROUND: Spontaneously ruptured hepatocellular carcinoma (HCC) with hemoperitoneum has a poor prognosis, especially in cases of cirrhosis. Patients usually present to emergency rooms (ERs) with acute abdomen. The aim of the present study was to determine the factors affecting mortality and to compare the prognosis of conservative treatment, transcatheter arterial embolization (TAE), or hepatectomy in these situations. METHODS: Fifty-four patients with spontaneously ruptured HCC diagnosed between January 2004 and August 2010 were enrolled in this retrospective review of clinical data. Grouping by survival or mortality, univariate and multivariate analyses of factors affecting 30-day mortality, and long-term survival were conducted. The outcomes of the various treatments were analyzed. RESULTS: After primary fluid resuscitation in the ER, 6 of 54 patients underwent conservative treatment. Emergency hepatectomy was performed on 19 patients; TAE was used for 29 patients, 18 of whom received staged hepatectomy thereafter. Poor liver function, prolonged international normalized ratio (INR), and conservative treatment were associated with increased 30-day mortality. Logistic regression analysis of cumulative survival revealed that INR ≥ 1.4, multiple intrahepatic HCC, and conservative treatment were related to poorer long-term survival. The patients who received hepatectomy, either immediate or staged after TAE, had higher survival rates of 85.2 % at 30 days and 62.2 % at 1 year. CONCLUSIONS: The treatment of ruptured HCC should be tailored to the individual case. Prolonged survival is possible in patients with preserved liver function through curative liver resection. Emergency physicians, radiologists, and surgeons play essential roles in managing these patients.

[Trauma-associated bleeding in the severely injured. Relevance, risk stratification and current therapy approaches]. / Traumaassoziierte Blutung beim Schwerverletzten. Relevanz, Risikostratifizierung und aktuelle Therapieansätze.

Of all trauma-related deaths 40% are due to exsanguination. The causes for acute, hemorrhaging are uncontrolled bleeding sources and the development of acute posttraumatic coagulopathy. Clinical observations and recent research results emphasize the key role of this disorder in acute trauma care. The present synopsis summarizes the results from different analyses based on datasets from severely injured patients derived from the Trauma Register of the German Trauma Society (DGU) on frequency, potential triggers and strategies to manage acute posttraumatic coagulopathy. In an extension to this work a clinical scoring system for early identification of patients at high risk for ongoing bleeding is presented. High risk patients seem to benefit from a more balanced transfusion regimen.

[Imaging in the emergency room]. / Bildgebung im Schockraum.

In order to reduce mortality in severely injured patients, a rapid radiologic diagnosis is essential. Sonography plays a role only as a focused assessment with sonography for trauma (FAST) to clarify free intraperitoneal fluid immediately on admittance. Today, whole-body multislice helical computed tomography (CT) has become increasingly important as a diagnostic tool. Based on the results of the CT scan, patients can be referred for laparotomy or safely classified for "wait and see" treatment. Although the reduction in injury-related mortality would outweigh the risk of radiation dose, the indiscriminate use of CT for patients with minor injuries is not justified and must be avoided.

Successful selective nonoperative management of abdominal gunshot wounds despite low penetrating trauma volumes.

OBJECTIVE: To determine whether selective nonoperative management of abdominal gunshot wounds (AGSW) is safe in trauma centers with a low volume of penetrating trauma. DESIGN: Retrospective study. SETTING: Academic level 1 trauma center with approximately 10% penetrating trauma. PATIENTS: All patients with anterior and posterior AGSW (January 1, 1999, through December 31, 2009), excluding tangential injuries, transfers, and deaths in the emergency department. Patients with hemodynamic instability or peritonitis received an urgent laparotomy. The remaining patients had selective nonoperative management. A delayed laparotomy was offered for worsening symptoms or worrisome computed tomography findings. MAIN OUTCOME MEASURES: Hospital stay, complications, and mortality. RESULTS: Of 125 AGSW patients, 38 (30%) were initially managed by selective nonoperative management (25 of 99 anterior and 13 of 26 posterior AGSW patients). Seven selective nonoperative management patients received delayed laparotomy as late as 11 hours after admission. At the end, 30 of the 125 patients (24%) were successfully managed without an operation (20 of 99 anterior and 10 of 26 posterior AGSW patients). There were no predictors of delayed laparotomy and no complications or mortality attributed to it. Ten patients (8%) had a nontherapeutic laparotomy, and 3 of them developed complications. CONCLUSIONS: Selective nonoperative management of AGSW is feasible and safe in trauma centers with low penetrating trauma volumes. Nearly 1 in 4 AGSW patients does not need a laparotomy, and nontherapeutic laparotomies are associated with complications. The volume of AGSW per se should not be an excuse for routine laparotomies. These data become particularly important because penetrating trauma volumes are decreasing around the country.

Prognosis of patients with spontaneous rupture of hepatocellular carcinoma in cirrhosis.

The treatment of cirrhotic patients with spontaneous rupture of hepatocellular carcinoma (HCC) is controversial and largely dependent on general conditions of the patients and compensation of the underlying cirrhosis. We retrospectively reviewed clinical, imaging and surgical records of 24 consecutive cirrhotic patients (17 males, 7 females; age range 52-88 years) with hemoperitoneum from spontaneous rupture of HCC observed from June 2004 to January 2010 at our Institution. When indicated, patients were referred to surgery or trans-arterial embolization (TAE). Advanced decompensated patients were conservatively treated and clinically followed up. Spontaneous rupture of HCC was assessed by aspiration of bloody ascites at paracentesis in all cases. The presence of large blood-clots over HCC and liver surface at US and/or CT was considered a specific sign of ruptured HCC in 14 cases. In two out of four patients who underwent TAE active bleeding from tumor surface could be demonstrated. In 2 cases, the active hemorrhage from the HCC surface could be assessed by contrast-enhanced ultrasonography. Four out of 24 patients underwent surgery. Three out of four of these patients died within 2 weeks, 8 months, and 20 months after operation, respectively. The remaining patient is still alive at 52 months follow-up. Four patients underwent TAE and died at 1, 2, 6 and 10 months after treatment, because of recurrent peritoneal bleeding and/or liver failure. Sixteen patients with ruptured HCC in the advanced Child C cirrhosis were treated conservatively with blood derivative transfusion and with procoagulant drugs. All patients, but one died within 2-18 days. One patient survived the acute hemorrhage from ruptured HCC and died of liver failure after 3 months. We concluded that spontaneous rupture of HCC is usually a fatal event in patients with poor liver function, even after successful TAE. In compensated patients, timely surgical treatment can result in long term and even tumor-free survival of the patient.

Rotura de arteria hepática aneurismática asociada con hepatitis isquémica / Rupture of hepatic artery aneurysm associated with ischemic hepatitis

Hepatic artery aneurysms are scarcely reported,mainly because of non-specific symptoms. More often,they are incidental findings during imaging studies toinvestigate other acute or chronic abdominal conditions.These aneurysms are usually detected in the sixthdecade of life, predominantly among males.We report the case of a 69 year-old female with anunsuspected huge hepatic artery aneurysm associatedwith ischemic hepatitis. Suspicion of aneurysm aroseduring imaging studies to clarify the origin of jaundiceand abdominal pain. After establishment of the diagnosis,but before open surgery, there was a spontaneousrupture of the aneurysm, which caused hemoperitoneumand death. The necropsy study confirmed ischemichepatitis.Hepatic artery aneurysms are second among thevisceral aneurysms, and may cause abdominal pain,jaundice, and hemorrhagic events.One should suspect abdominal aneurysms in elderlypatients with unclear abdominal pain, and thishypothesis should be ruled out by imaging studies(AU)

La publicación de trabajos sobre aneurismas en laarteria hepática es escasa, debido a los síntomas no específicosy a que constituyen hallazgos incidentales duranteinvestigación de otras condiciones abdominalesagudas o crónicas. Estos aneurismas son más frecuentesen varones y en la sexta década de la vida.Presentamos el caso de una mujer de 69 años deedad que ingresa en el hospital con un aneurisma dearteria hepática no sospechado previamente, asociadocon hepatitis isquémica. La sospecha de aneurisma empezódurante estudio de imágenes para aclaramientodel origen de ictericia y dolor abdominal. Después deconfirmado el diagnóstico, pero antes de la operaciónplaneada, ocurrió rotura espontánea del aneurismacausando hemoperitoneo y muerte. El estudio de necropsiaconfirmó hepatitis isquémica.Los aneurismas de la arteria hepática son los segundosentre los aneurismas viscerales y pueden causardolor abdominal, ictericia y eventos hemorrágicos.Debemos sospechar de aneurisma visceral en ancianoscon dolor abdominal no aclarada, posibilidad que debeser descartada por estudios de imágenes(AU)

Haemoperitoneum in horses: a retrospective review of 54 cases.

This retrospective study was conducted in the UK and identifies the most frequent causes, diagnoses, treatment and prognoses for short- and long-term survival in 54 cases of horses with haemoperitoneum. Clinical signs of haemorrhagic shock and colic were common, and abdominal ultrasound was very useful for the identification of haemoperitoneum. Causes of haemoperitoneum included uterine injury (22 per cent), involvement of specific blood vessels (20 per cent), splenic injury (19 per cent), neoplasia (13 per cent) and other (4 per cent). No source was identified in 22 per cent of cases. Fifty-seven per cent of cases underwent exploratory laparotomy. Of the surgical cases, a diagnosis was made in 65 per cent, with 42 per cent surviving to discharge. It was felt that exploratory laparotomy had both diagnostic and therapeutic implications. Twenty-eight per cent of cases died, and 33 per cent were euthanased, whereas 39 per cent survived to be discharged from the hospital, with 35 per cent of these surviving in the long term. Idiopathic haemoperitoneum was associated with the best outcome for long-term survival.

Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries.

BACKGROUND: The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach. Major hepatic necrosis (MHN) is a morbid, but underappreciated complication of AE in this patient population. This study will examine the risk factors and outcomes of patients with high-grade liver injures managed with AE who developed the complication of MHN. METHODS: Patients admitted to the R Adams Cowley Shock Trauma Center between January 2002 and December 2007 with high-grade blunt or penetrating liver injuries (grades III-VI) were identified from the trauma registry and the medical records were retrospectively reviewed. Demographic and injury specific data, complications, and admission physiologic variables were collected. Patients who had therapeutic AE, either preoperatively or postoperatively, and went on to develop liver-related complications including MHN were reviewed. RESULTS: There were 538 patients with high-grade liver injuries admitted during a 5-year period. One hundred and sixteen patients (22%) underwent angiography, and 71 (13%) had a therapeutic AE. Sixteen patients (22.5%) had grade III injuries, 44 (62%) had grade IV injuries, and 11 (15.5%) had grade V injuries. Overall mortality in this group was 14% with eight patients (11.3%) dying as a result of their liver injury. Complication rates were 18.8%, 65.9%, and 100% in the patients with grades III, IV, and V injuries, respectively, for an overall complication rate of 60.6%. Thirty patients (42.2%) went on to develop MHN. Patients who developed MHN were compared with those who did not. Baseline characteristics, Injury Severity Score, and hemodynamic parameters at admission were no different between the two groups. Patients with MHN had higher grade injuries, required significantly more blood product transfusions, and had a significantly longer length of stay (all p < 0.001). Patients who developed MHN were more likely to have undergone operative intervention (96.7% vs. 41.5%, p < 0.001), with 87% having a damage control laparotomy. Other liver-related complications occurred more frequently in the patients that developed MHN (60.0% vs. 34.1%, p = 0.03). However, mortality was not different in the two groups. CONCLUSION: High-grade liver injuries pose significant challenges to those who care for trauma patients. Many patients can be successfully managed nonoperatively, but there are still patients that require laparotomy. AE is the logical augmentation of damage control techniques for controlling hemorrhage. However, given the nature and severity of these injuries, these therapies are not without complications. MHN was found to be a common complication in our study. It tended to occur in high-grade injures, was associated with higher complication rates, longer hospital length of stay, and higher transfusion requirements. Management of MHN can be challenging. Factors that still need to be elucidated are the role of perihepatic packing and timing of second look operation.

[Maternal death after spontaneous rupture of a uterine artery immediately following delivery: a case report]. / Décès maternel après rupture spontanée d'une artère utérine dans le post-partum immédiat : à propos d'un cas.

We report the case of a maternal death occurring after spontaneous rupture of a uterine artery immediately following delivery. The patient presented abdominal pain and a collapsus one hour after a normal delivery. Laparotomy revealed massive haemoperitoneum and intraperitoneal bleeding from the right uterine artery. Ligature of the uterine artery and hemostasis hysterectomy were performed but the patient died of multivisceral failure 18 h after the delivery. This is the first case report of maternal death occurring after spontaneous rupture of a uterine artery.

Hemoperitoneo y muerte por rotura de metástasis hepatoesplénicas de tumor testicular / Hemoperitoneum and death due to hepatoesplenic methastasis rupture in a testicular tumor

Presentamos un caso de tumor germinal mixto de testículo, en estadio III-C (AJCC-UICC), con evolución letal, por hemoperitoneo masivo por rotura de metástasis hepáticas y esplénicas

We present a case of a mix germinal testicular tumor,in III-C (AJCC-UICC) stage, at a terminal phase due to massive methastasis rupture at hepatic and splenic methastasis locations