Moore Ee

Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents

BACKGROUND The sequelae of blunt injury to the carotid arteries are unusual, but pseudoaneurysms causing subsequent strokes are devastating. The utility of treatment of these pseudoaneurysms was examined. METHODS All patients at a Level I trauma center with previously documented traumatic risk factors were assessed for blunt injury to the carotid arteries and, when a pseudoaneurysm was present, a self-expanding metallic stent was placed across the lesion and the patient placed on anticoagulation. Follow-up arteriograms were obtained in 2 months and every 6 months thereafter. RESULTS Fourteen patients (7 men, 7 women) with an average age of 27 years, an Injury Severity Score of 38, had formed pseudoaneurysms in 16 extracranial internal carotid arteries. These were stented with metallic endoprostheses. No strokes occurred after the placement of the stents. Mean follow-up period has been 2.5 years. CONCLUSIONS Use of metallic endoprostheses is an effective method to treat this potentially devastating injury. However, longer follow-up and more patients studied are needed to further examine this promising treatment.

Emergency department thoracotomy in children ― A critical analysis

Abstract Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.

CD11b blockade prevents lung injury despite neutrophil priming after gut ischemia/reperfusion

Gut ischemia/reperfusion (I/R) provokes lung injury via a mechanism that involves neutrophils [polymorphonuclear neutrophils (PMNs)]. CD11b/CD18 (alpha mB2) is the integrin receptor on PMNs critical for adhesion-dependent oxidative burst. The purpose of this study was to investigate the mechanistic role of CD11b in the process of gut I/R-induced lung injury. Sprague-Dawley rats underwent 45 minutes of superior mesenteric artery (SMA) occlusion with and without CD11b monoclonal antibody treatment (IB6) (1 mg/kg, i.v.), before SMA clamping. At 2-hour reperfusion, PMN presence in tissue was quantitated by myeloperoxidase activity and circulating PMN priming determined by the difference in superoxide production with and without N-formyl-methionyl-leucyl-phenylalanine, whereas lung leak was assessed by 125I-albumin lung/blood ratio. In sum, CD11b blockade prevented gut I/R-induced lung leak, but did not attenuate gut I/R-induced PMN priming or tissue PMN accumulation. In conclusion, gut I/R promotes PMN priming and PMN adhesion in both local and distant beds via receptors other than CD11b, but this B2 integrin receptor is critical for PMN-mediated endothelial injury.

Balloon tamponade for bilobar transfixing hepatic gunshot wounds.

The nonresectional approach to major liver trauma is clearly preferred. Unfortunately, trachotomy with vessel ligation, selective hepatic arterial ligation, perihepatic pack, and fibrin glue are not viable options with high-energy bilobar liver injuries. We have fashioned a balloon tamponade device that has proved very effective for these transfixing hepatic gunshot wounds.

Graded experimental myocardial contusion: Impact on cardiac rhythm, coronary artery flow, ventricular function, and myocardial oxygen consumption

Current management of myocardial contusion is based on experience with ischemic heart disease, but the mechanism responsible for cardiac dysfunction may be quite different. The purpose of this study was to characterize the pathophysiology of myocardial contusion in a controlled animal model. Sprague-Dawley rat hearts were prepared on a standard Langendorff apparatus, and myocardial function (DP, + dP/dT, - dP/dT) measured via a left ventricular balloon. Bipolar atrial and ventricular leads were placed to define conduction changes. Coronary sinus effluent was sampled for pO2, pH, creatine phosphokinase (CPK), and lactic dehydrogenase (LDH). The hearts were freeze-clamped to measure phosphocreatine (PC) and adenosine triphosphate (ATP). Myocardial contusion was produced by a single blow with a weighted pendulum. Hearts were divided into control (n = 5), moderate impact--Group I (n = 5), and major impact--Group II (n = 5). Group I sustained a 25% decrease in function after an impact of 78 +/- 5 mJoules/gm, and Group II a 50% deficit after 87 +/- 7 mJoules/gm. Impact resulted in complete electrical arrest, followed by sequential ventricular, atrial, and AV nodal recovery; recovery time correlated directly with degree of injury. Coronary flow at 2 min postinjury was decreased (p less than 0.05) in Group I (12.8 +/- 0.8 ml/min) and Group II (11.5 +/- 1.3) compared to control (17.2 +/- 0.5), and returned to baseline levels at 20 min. LDH and CPK levels were twice as high in Group II as in Group I. The PC/ATP ratio in Group II increased from 1.63 at baseline to 2.54 (p less than 0.05) at 25 min, confirming ischemic reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative cardiac sampling following penetrating wounds: a technique for early detection of traumatic intracardiac shunts--case report.

Intracardiac shunts complicating penetrating heart wounds may be unrecognized during the early postoperative period due to the insensitivity of noninvasive diagnostic tests. This case demonstrates the value of intraoperative cardiac sampling for oxygen saturation to identify an otherwise occult aorta-right ventricular fistula secondary to a precordial stab wound, ultimately progressing to a 1.9:1 shunt requiring operative repair.

Traumatic subarachnoid-pleural fistula.

Subarachnoid pleural fistulas (SPFs) have been reported as complications of penetrating trauma, blunt trauma, thoracic surgery, spinal surgery, and other uncommon causes. Traumatic SPFs are rare complications associated with thoracic spine injury. The overwhelming majority of reports describe patients presenting with persistent pleural effusions; however, a handful also describe air in the spinal canal (pneumorrhachis) or around the brain (pneumocephalus) at the initial presentation. Most reviews fail to distinguish these two different presentations and under report the number of published cases of traumatic SPFs. Herein, we present a case of traumatic SPF presenting with tension pneumothorax, pneumorrhachis, and pneumocephalus. This prompted our comprehensive review of the literature adding 39 further cases of postinjury SPFs. Our analysis of this database suggests two distinct patterns of SPFs with disparate pathophysiology, management, and outcome.