1/18. Multivascular trauma on an adolescent. Perioperative management.Penetrating vascular injury, in particular at the neck, is a life-threatening trauma not only of the nature and the anatomic proximity of cardiovascular, aerodigestive, glandular and neurologic system but also of the development of early and late complications. The following case report describes our experience with a penetrating wound patient, who was admitted to our emergencies twelve hours after the accident. The only demonstrable objective signs included a large hematoma at the right-side of the neck and distended mediastinum on the chest X-ray. As the patient was cardiovascularly unstable he was immediately transported to the theater without any angiography. The mandatory operative exploration was initially unsuccessful and a median sternotomy with a standard cardiopulmonary bypass and deep hypothermia circulatory arrest was established to restore all the vascular lesions. Actually, the patient was in critical condition with a rupture of the right internal jugular vein, a large pseudoaneurysm of the innominate artery and an avulsion of the ascending aorta with the suspicion of a cardiac tamponade. The postoperative period lasted two full months, while complications appeared. The substantial message from this multivascular trauma is the early diagnosis of the life-threatening complications as exsanguinations, ventricular fibrillation and the ability to minimize postoperative complications, which will impair the normal functional life of the patient.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
2/18. Facial fractures and related injuries: a ten-year retrospective analysis.A retrospective analysis of 828 patients with significant midface or mandibular fractures was undertaken to illustrate the multisystem nature of traumatic injuries associated with fracture of the facial skeleton, covering the period from 1985 to 1994. Special emphasis was placed on determining associated injuries sustained as well as epidemiological information. The experience presented differs from other large series in the literature in that the predominant mechanism of injury is motor vehicle accidents (67%) rather than assaults. Of the patients reviewed, 89% sustained significant associated injuries. Closed head trauma with documented loss of consciousness was noted most frequently (40%), followed by extremity fractures (33%), thoracic trauma (29%), and traumatic brain injuries (25%). Only 11% of patients sustained facial fractures without concomitant injury.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
3/18. A novel approach to the treatment of gunshot injuries to the sacrum.Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5-9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.- - - - - - - - - - ranking = 2keywords = nature (Clic here for more details about this article) |
4/18. Complete, superior labral radial tear and type II slap tear associated with greater tuberosity fracture.This case report presents a unique variant of superior labral-bicep complex injury. The combination of a complete anterior-superior radial tear of the labrum and bicep anchor instability has not been described in previous classifications of these injuries. The injury was traumatic in nature and was associated with a displaced fracture of the greater tuberosity. The labral pathology was treated by an anatomic repair technique as described. Rationale for the repair performed, as well as implications of the injury treated by debridement alone, are discussed. Clinicians should be aware of different patterns of superior labral-bicep complex injuries and the implications on function and stability of the glenohumeral joint.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
5/18. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a glasgow coma scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
6/18. Nerve sheath tumors involving the sacrum. Case report and classification scheme.Nerve sheath tumors that involve the sacrum are rare. Delayed presentation is common because of their slow-growing nature, the permissive surrounding anatomical environment, and nonspecific symptoms. Consequently, these tumors are usually of considerable size at the time of diagnosis. The authors discuss a case of a sacral nerve sheath tumor. They also propose a classification scheme for these tumors based on their location with respect to the sacrum into three types (Types I-III). Type I tumors are confined to the sacrum; Type II originate within the sacrum but then locally metastasize through the anterior and posterior sacral walls into the presacral and subcutaneous spaces, respectively; and Type III are located primarily in the presacral/retroperitoneal area. The overwhelming majority of sacral nerve sheath tumors are schwannomas. Neurofibromas and malignant nerve sheath tumors are exceedingly rare. Regardless of their histological features, the goal of treatment is complete excision. Adjuvant radiotherapy may be used in patients in whom resection was subtotal. Approaches to the sacrum can generally be classified as anterior or posterior. Type I tumors may be resected via a posterior approach alone, Type III may require an anterior approach, and Type II tumors usually require combined anterior-posterior surgery.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
7/18. Inadvertent embolization of a persistent sciatic artery in pelvis trauma.We describe a case of unilateral persistent sciatic artery (PSA), a rare vascular anomaly, in a 43-year-old woman with severe multiple trauma. A small amount of diluted embolization particles went into this vessel during emergent endovascular therapy under fluoroscopic monitoring. The procedure was immediately stopped when the true nature of the anatomic variant was recognized. Fortunately, an ischemic event of the lower leg did not occur. The imaging findings of computed tomography and digital subtraction angiography are presented and the relevant literature is reviewed.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
8/18. Suicidal bus bombing of French Nationals in pakistan: physical injuries and management of survivors.BACKGROUND: Suicidal bombing is particularly devastating and an increasingly common form of terrorist violence. In this paper, we present an epidemiologic description of the physical injuries of patients who survived the suicidal bombing attack in the context of the limited medical resources of a developing nation. methods: The management of individual patients was reviewed from a preprinted trauma form. Information on the nature of injuries, operative management and hospital course was recorded and data analyzed using the Trauma Registry. RESULTS: Twelve survivors out of 36 bomb blast victims brought to the Aga Khan University Hospital were transferred from primary receiving hospitals. The average number of injuries per patient was eight. The mean injury severity score was 10.8. The majority of patients had secondary and tertiary blast injuries. Most of the survivors had calcaneal injuries; these have not been reported in the literature in similar terrorist attacks. Twelve operative interventions were undertaken. All of the 12 patients were stabilized and evacuated within 24 h of admission. CONCLUSIONS: All of the 12 patients transferred to the Aga Khan University Hospital survived. Unlike the reported injuries, calcaneal fractures were most commonly encountered in the survivors.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
9/18. Complex pain consultations in the pediatric intensive care unit.The assessment and management of pain in children is not always easy and it is clearly more difficult in the critical care setting. pain management is further complicated in this vulnerable population by the nature of their critical condition, the complexity and multidimensionality of their illness or injuries, and the intensity of emotions in this environment. A variety of pain syndromes are encountered in the pediatric intensive care unit, and the staff there may not be familiar with or comfortable managing these cases. Pain assessment and treatment can be more appropriately managed when guided by the experts of a multidisciplinary pediatric pain service.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
10/18. Posttraumatic active bleeding of mediastinal mixed vascular malformation: a case report.A case of an actively bleeding mediastinal mass in a 4-year-old boy who sustained multitrauma is described. A computed tomography (CT) scan of the chest upon admission demonstrated a mediastinal mass, which enlarged significantly as seen by repeat CT scan at 3 days with a concomitant drop in serum hemoglobin levels. The lesion was excised, and pathological examination established the diagnosis of a lymphatic-venous malformation containing bloody fluid. Lymphatic-venous malformations are rare vascular malformations and are usually found in the head and neck and less commonly at other sites. Spontaneous bleeding is a known complication, and there are few reports describing posttraumatic hemorrhage. Our case is the first description in the English medical literature of a posttraumatic bleeding mediastinal mixed vascular malformation and includes sequential CT scans illustrating the dynamic nature of hemorrhage.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
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