Kahdi Udobi

Role of ultrasonography in penetrating abdominal trauma: A prospective clinical study

BACKGROUND Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.

In vivo visualization of reactive oxidants and leukocyte-endothelial adherence following hemorrhagic shock

The generation of oxygen radicals during leukocyte-endothelial cell interaction is considered to represent one of the fundamental steps of microvascular injury following ischemia and reperfusion. Indirect evidence also suggests that this relationship may be important following hemorrhagic shock. The purpose of this study was to characterize the temporal changes of reactive oxygen species (ROS) in the mesenteric microvascular endothelium, in vivo, as a consequence of hemorrhagic shock and reperfusion, and to correlate this ROS production to leukocyte adherence. Following a control period, blood was withdrawn to reduce the mean arterial pressure to 40 mmHg for 1 h in urethane-anesthetized rats. Mesenteric venules in a transilluminated segment of small intestine were examined to quantitate changes in ROS generation and leukocyte adherence. Sprague-Dawley rats were injected with dihydrorhodamine 123, a hydroperoxide-sensitive fluorescent probe that is trapped within viable cells as a nonfluorescent form and then converted to the mitochondrion-selective form rhodamine 123 by hydroperoxides. The fluorescent light emission from rhodamine 123 was recorded with digital microscopy and downloaded to a computerized image analysis program. Our results demonstrated an 80% increase in ROS generation beginning within 5 min into resuscitation and a 10-fold increase in leukocyte adherence that occurred at 10 min after resuscitation. Both ROS generation and leukocyte adherence were attenuated with pre-shock administration of platelet activating factor (PAF) antagonist, WEB 2086, and the CD11/CD18a antibody, anti-LFA-1&bgr;. Our findings suggest that ROS production in endothelial cells is increased during reperfusion following hemorrhagic shock and that the mechanism of expression is mediated in part by both PAF expression and subsequent leukocyte adherence.

Hypothermia reduces microvascular permeability and reactive oxygen species expression after hemorrhagic shock

BACKGROUND Hypothermia is a frequent manifestation after trauma-induced hemorrhagic shock. Clinical studies have suggested that hypothermia is an independent risk variable predisposing patients to an increase in morbidity. Thus, most of the current goal-directed resuscitation protocols are aimed at the establishment of euthermia. However, recent data suggest that hypothermia may provide protection by attenuating the inflammatory response after hemorrhagic shock. The purpose of this study was twofold: to examine the effects of mild to moderate hypothermia on barrier function after hemorrhagic shock, and to determine the role of reactive oxygen species (ROS) in this process. METHODS After a control period, blood was withdrawn to reduce the mean arterial pressure to 40 mm Hg for 1 hour in urethane-anesthetized rats. Mesenteric postcapillary venules in a transilluminated segment of small intestine were examined to quantitate changes in permeability and ROS expression. Sprague-Dawley rats received an intravenous injection of fluorescein isothiocyanate (FITC)-albumin during the control period. The fluorescent light intensity emitted from the FITC-albumin was recorded with digital microscopy within the lumen of the microvasculature and compared with the intensity of light in the extravascular space. The images were downloaded to a computerized image analysis program that quantitates changes in light intensity. This change in light intensity represents albumin-FITC extravasation. RESULTS Our results demonstrated a marked increase in albumin leakage after hemorrhagic shock that was significantly attenuated with mild (34 degrees C) and moderate (30 degrees C) hypothermia. In addition, hypothermia attenuated ROS expression after hemorrhagic shock. CONCLUSION These data suggest that hypothermia may protect barrier integrity after hemorrhagic shock by inhibition of oxygen radical expression.

Bowel necrosis caused by water in jejunal feeding.

BACKGROUND Fifteen reports of bowel necrosis in patients receiving jejunal feeding have been reported. Etiology remains unexplained. METHODS A patient with a 60% burn receiving jejunostomy tube feeding developed hypernatremia and was given distilled water in the jejunum, 400 mL every 2 hours. One week later, he developed an acute abdomen with abdominal distention. At operation, he had 4 L of cloudy fluid containing jejunal feeding. Three large duodenal perforations were present. The jejunostomy site was normal. In an animal study, water or normal saline (0.85% NaCl) were infused into the mid small bowel, and sections of bowel were taken 5 minutes later for histologic study. RESULTS Animal study of the effect of water in the rat intestine revealed disruption of intestinal epithelium. It is suggested that disruption of epithelium by electrolyte-free water may permit digestion of the bowel wall and result in perforation, as was observed in this patient. This mechanism may have been responsible for some of the cases reported in the literature. CONCLUSIONS Tap or distilled water may injure intestinal epithelium and should not be infused directly into the small bowel as jejunal feeding.

Heme-oxygenase-1 mRNA expression affects hemorrhagic shock-induced leukocyte adherence.

BACKGROUND Hemorrhagic shock-related leukocyte adherence to endothelial cells is a key step in microvascular injury-related organ damage. Heme-oxygenase-1 (HO-1) metabolizes heme, a potent cytotoxic agent, to carbon monoxide and biliverdin. We hypothesized that changing HO-1 expression would change leukocyte adherence after hemorrhagic shock. METHODS Rats were administered hemin, zinc protoporphyrin, or vehicle 6 hours before surgery. HO-1 expression was determined by reverse-transcriptase polymerase chain reaction in various tissues. Shock was induced in urethane-anesthetized animals by decreasing mean arterial blood pressure to 40 mm Hg for 60 minutes, followed by standard resuscitation measures. Leukocyte adherence was measured by intravital microscopy in rat mesenteric venules. RESULTS Hemin, hemorrhagic shock, and the combination resulted in significantly increased HO-1 expression, whereas zinc-protoporphyrin (ZNPP) resulted in significantly decreased leukocyte adherence. After hemorrhagic shock and hemin administration, leukocyte adherence was significantly decreased 60 minutes into resuscitation (7.92 +/- 2.29 vs. 4.84 +/- 0.71 cells/100 microm, p < 0.05) and significantly increased after ZNPP plus shock (14.08 +/- 3.95, p <or= 0.01). CONCLUSION The results demonstrate that hemin increases and ZNPP decreases HO-1 mRNA expression and attenuates hemorrhagic shock-induced leukocyte adherence, whereas ZNPP decreases it. These results suggest that by changing HO-1 expression, leukocyte adherence resulting from oxidant injury may be altered.

An opportunity for improvement in trauma care: 8-week booster vaccination adherence among patients after trauma splenectomy

Background Splenectomies are common after abdominal trauma, and measures must be taken to prevent infection, namely, the administration of available conjugate vaccinations against encapsulated organisms. While initial immunization is frequently completed prior to discharge, the Advisory Council on Immunization Practices recommends administration of an 8‐week vaccination booster against S. pneumoniae, and compliance with this practice is unknown. We hypothesized that patients undergoing splenectomy for trauma would not routinely receive the recommended immunization and subsequent booster. Methods All trauma admissions at our center who required splenectomy secondary to trauma between 2010 and 2015 were included. Demographic and injury data, splenectomy dates, immunization documentation, subsequent boosters received, and outcomes were collected from the medical record. Results Of the 9,965 patients observed, 44 patients underwent splenectomy, with 31 patients meeting inclusion/exclusion criteria. Two patients received subsequent boosters during office or hospital visits; however, no patient received any booster within Advisory Council on Immunization Practices’ recommended timeframe with median time to subsequent boosters of 22 months. Seven patients have had a subsequent admission for infection or sepsis, with one presenting with S. pneumoniae meningitis. None of the patients subsequently admitted for infection or sepsis had received boosters. Conclusion While trauma patients at our institution receive recommended immunizations after splenectomy prior to discharge, they receive boosters at a suboptimal rate and beyond the advised timeframe. We speculate that this phenomenon is widespread in the American trauma population. These data suggest a need for improved patient and provider education and coordination with primary care practitioners to ensure ideal defense against infectious complications.

Cecal volvulus with gangrene following Mitrofanoff procedure

The appendico-vesicostomy (Mitrofanoff procedure) is a procedure for continent urinary tract reconstruction usually in children and young adults. This conduit originally fashioned from the appendix is easily catheterized through an abdominal wall stoma. It is most commonly indicated for neurogenic bladder but has also been performed for exstrophy and epispadias. The most frequent complications are stomal stenosis and leakage which sometimes require revisional procedures. Bowel obstruction is rare following this procedure. To our knowledge there are no reports of cecal volvulus following the Mitrofanoff procedure. We report on a case of cecal volvulus which progressed to frank gangrene with perforation, peritonitis and sepsis.

The Role of Dr. Colonel Vance H. Marchbanks in developing an oxygen delivery system: A “Forgotten First” in Aviation and Aerospace

In our series of unsung or forgotten medical heroes, we first published a manuscript on Alvin Blunt, Jr, M.D. who was the first African American MASH physician in the Korean War. Dr. Kenneth L. Wilson’s manuscript changed United States military history. Our second manuscript in our series, Medical Miracle in Indianola, Mississippi: The Untold Story of Dr. Clinton Battle and the Indianola Conjoined Siamese Twins, introduces the world to a 29-year-old physician who vaginally delivered the first set of conjoined twins to be successfully separated and both survived the operation. This great feat was done at Rev. John and Missouri Matthews’ home without anesthetics or ultrasound. Dr. Battle died dejected because he never received any credit for this magnificent accomplishment in medical history. In this manuscript, we present the compelling story of Dr. Colonel Vance Marchbanks, who monitored astronaut John Glen during his historic space flight. Dr. Marchbanks was a pioneer Flight Surgeon who developed an oxygen delivery system that enabled flight crews to fly at higher altitudes.

Traumatic Injuries Requiring Simultaneous Emergent Operative Procedures, Knife Wounds to the Top of the Skull and the Abdomen

The simultaneous commencement of operative interventions by two or more surgical teams in the multiply injured patient is gaining more acceptance.

Appendiceal perforation, necrotizing groin infection and spermatic cord necrosis in a case of Amyand’s hernia

Highlights • Amyand’s hernias are an uncommon variant of inguinal hernia.• Early recognition of this hernia type may improve patient care and outcome.• Treatment for Amyands hernias is dictated by additional factors, which has led to a classification scheme.• There is no consensus on the approach to repair of these hernias but various described approaches have shown success.