Sanjiv Gray

Clostridium sordelli causing malignant edema in a trauma patient: a case report and review of literature

Clostridium sordelli infection is a rare but potentially lethal infection associated with abortions, injury, contaminated wounds, and illicit drug use. It causes a recognizable syndrome with marked leukocytosis. Rapid diagnosis and aggressive sepsis management is required for optimal outcome. We report a case in a trauma patient with delayed presentation after sustaining facial trauma with soil contamination. The critical care management is summarized and a review of the literature.

Pucker sign in irreducible posterolateral knee dislocation

24 years old male seen in the trauma bay involved in a motor vehicle accident with rollover landing on its roof. He was partially ejected with his right leg hyperflexed and entrapped. The patient was stable with complaints of right knee pain. There was dimpling of the right distal medial thigh (A, B). After unsuccessful attempts at closed reduction, the patient was taken for open reduction. There was entrapment of the femoral condyle in the extensor mechanism. The soft tissues were released and the condyle reduced back into its normal position. The extensor mechanism was then repaired. The patient had palpable posterior tibial and dorsalis pedis pulses after completion of the procedure. The mechanism for posterolateral knee dislocation is valgus and rotational stress during knee flexion. The medial cruciate ligament, anterior cruciate ligament, and the posterior cruciate ligament are usually injured in posterolateral knee dislocation with incarceration of the capsule and ligamentous structures in the intercondylar notch. Early open reduction is indicated as it is generally considered irreducible by closed reduction. The pucker sign is considered pathognomonic. On Radiographs with attention to the patella shows the patella maintaining its in-line attachments to the tibial tuberosity and is reduced with respect to the proximal tibia but dislocated with respect to the distal femur. At the follow up the patient is ambulatory after rehabilitation. Figure 1: Xray showing posterolateral dislocation of the knee.

Paraplegia Following Spinal Cord Contusion from an Indirect Gunshot Injury

Spinal cord injuries are debilitating and life threatening. Paraplegia due to direct traumatic gunshot injury to the spinal cord is common. The most common cause of spinal cord injury is road traffic accidents. This is followed by spinal cord injury due to a fall from a height. Most of the spinal cord injuries due to gunshot wounds occur as a result of direct traumatic effects. We present a rare case of a 49-year-old male with trauma. He developed paraplegia after a gunshot wound injury to the neck and contusion to the spinal cord, with no direct trauma. Paraplegia due to direct gunshot injury can have many different outcomes. In our case, the patient was managed conservatively, and the outcome was favorable.

A case of recurrent pneumatosis intestinalis

Abstract Pneumatosis intestinalis (PI), defined as free gas in the bowel wall, is associated with autoimmune conditions, drugs, pulmonary disease and many other etiologies. Patients with findings of PI may have variable clinical presentations, ranging from asymptomatic to acute abdomen necessitating urgent surgery. Here, we present the case of an individual with recurrent PI whose suspected etiologies ultimately varied from benign to lethal between visits. We discuss the clinical management of each case, perform post-hoc application of a proposed treatment algorithm, and highlight areas for future research.

Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y gastric bypass

Abstract Adult intussusception is a rare complication after laparoscopic Roux-En-Y gastric bypass (LRYGB) surgery. Incidence of intussusception is on the rise as the demand of bariatric surgeries is increased to treat morbid obesity. Among the bariatric surgeries, LRYGB gastric bypass results in significantly higher weight loss with thinning of the mesentery resulting in increased risk for intussusception. Majority of intussusception cases after gastric bypass have been reported in non-pregnant patients. We report a case of retrograde jejunojejunal intussusception in 6 weeks pregnant female following laparoscopic gastric bypass, which was diagnosed with abdominal magnetic resonance imaging and managed successfully with resection and revision of the anastomosis.

Optimizing Care for Trauma Patients with Obesity

Obesity is a growing epidemic that has been contributing to the increasing cost of healthcare. Its prevalence is now approximately 37%. Morbid obesity is associated with increased morbidity and mortality in trauma patients. An increased recognition of obesity as a chronic disease and a better understanding of its pathophysiology can allow for proper preparation and accommodative measures to improve resuscitation and subsequent care, thereby improving trauma outcomes. The aim of this review is to provide an overview of the scope of the problem. This review also provides evidence-based recommendations for the optimal resuscitation sequence for obese patients.

Blunt Laryngeal Fracture Status Post Fall on a Paintball Gun

Laryngeal fracture is a rare but potentially lethal injury. A high degree of suspicion along with an expeditious investigation is warranted to prevent airway complications. The initial assessment of the airway is vital as the patient can suffer a severe anoxic brain injury. If the patient is stable, a computed tomography (CT) scan of the neck should be obtained; this was done urgently for our patient and was managed without any extraneous intervention. We report a case of a 38-year-old man that presented to the emergency room with anterior neck pain after falling onto the back of a paintball gun. The patient was managed conservatively and favorable outcomes were obtained.

Resuscitative Endovascular Balloon Occlusion of the Aorta as an Adjunct in a Patient with Neurogenic Shock

Aortic occlusion is used during trauma resuscitation for patients with profound shock and cardiac arrest. Aortic occlusion increases coronary and cerebral perfusion permitting time for interventions in an attempt to salvage moribund patients. Resuscitative endovascular occlusion of the aorta (REBOA) is a less invasive method of aortic occlusion and its indications are being defined, but it is used primarily for noncompressible torso hemorrhage. This case is the first report of the use of REBOA for neurogenic shock in a trauma patient. The patient presented after a motorcycle accident with altered mental status and hypotension. The patient was resuscitated with blood products and REBOA used as an adjunct to maintain cardiac and cerebral perfusion. The patient underwent stabilization of his spinal injuries and is currently undergoing rehabilitation. There were no complications related to the REBOA.

Vanishing lung syndrome in a patient with HIV infection and recurrent pneumothorax

Vanishing lung syndrome (VLS) is a rare chronic, progressive clinical entity seen in smokers characterized by giant emphysematous bullae mainly in the upper lobes. Extensive paraseptal emphysema coalesces to form giant bullae, compressing the normal lung parenchyma. The criteria for diagnosis based on radiography was defined by Roberts et al in 1987 and includes the presence of giant bulla in one or both upper lobes, occupying at least one third of the hemithorax and compressing the surrounding normal lung parenchyma. HIV infection can worsen the disease process. We report a 56 year-old HIV positive male with a smoking history of 30 pack-years smoking history who presented to the Emergency room with chronic chest pain, dyspnea, and cough for 2-3 weeks duration. He had a history of COPD and had multiple prior admissions for recurrent pneumothoraces. Chest radiography (A) showed hyperlucent and hyperinflated lung with bilateral pleural thickening and bilateral severe bullous emphysematous changes which was suggestive of vanishing lung syndrome. Computed tomography of the chest confirmed these findings (B). Chest tube was placed on the left side for treatment of the pneumothorax. The patient had refused lung reduction surgery in the past. He was counseled on smoking cessation and was discharged home with a Heimlich valve catheter. The main complication of VLS is pneumothorax. Lung reduction surgery such as bullectomy results in improvements in dyspnea, gas exchange, and exercise tolerance. Clinical should be aware of the condition and early referral for lung reduction surgery is required. Smoking cessation is essential.

Successful laparoscopic repair of gastro-gastric fistula following Roux-en-Y gastric bypass at Harlem Community Hospital

Abstract Gastro-gastric fistula is a communication between the gastric remnant and gastric pouch. It is a rare complication of Roux-en-Y gastric bypass. It is caused by anastomotic leak, marginal ulcers, distal obstruction or erosion from foreign body. In this case report, we are presenting a successful laparoscopic repair of gastro-gastric fistula in a patient who presented with weight gain after initial loss.