Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury

BACKGROUND

Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking.

METHODS

This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes.

RESULTS

A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes.

CONCLUSIONS

The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.

Aortic Transection after Blunt Abdominal Trauma in a Child

Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury after a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.

Traumatic thoracoabdominal hernia repair using a novel chest-wall reconstruction technique: a case report

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.

The use of computed tomography imaging for abdominal seatbelt sign: A single-center, prospective evaluation

INTRODUCTION

Guidelines surrounding abdominal seat belt sign (SBS) were made prior to the use of modern computed tomography (CT) imaging. We sought to prospectively determine whether a negative CT scan is associated with the absence of hollow viscus injury (HVI), and we hypothesized that trauma patients with an abdominal SBS without CT imaging findings would not have a hollow viscus injury (HVI).

METHODS

A prospective cohort of patients with SBS was compiled over one year. Subjects were divided into those with and without HVI. Covariate distributions were summarized by group. Bivariate tests and logistic regression were used to investigate associations between covariates and HVI.

RESULTS

Of 220 patients with SBS, the incidence of HVI was 7% (n = 15). Radiographic findings were strongly associated with HVI and no patients with a negative CT scan had HVI. Free fluid was seen in 80% (12) of patients with HVI, whereas it was found in only 11% (23) without injury. A composite variable for negative CT scan was found to be associated with the absence of HVI: (Fisher's exact 1-tailed p, doubled = 0.014).

CONCLUSION

In this study, the incidence of HVI with SBS is lower than previously reported, and no patients with negative CT imaging required an operation for HVI-suggesting there is a population of patients with SBS who could be discharged from the emergency room. A prospective multicenter study is needed to confirm these findings.

Forensic and Clinical Issues in a Case of Motorcycle Blunt Trauma and Bilateral Carotid Artery Dissection

Internal carotid artery dissection (ICAD) after motorcycle accidents is unusual but life threatening if not promptly diagnosed and treated. We report the case of a motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma and indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by computed tomography angiogram 5 days after the accident. Here in, starting from a medicolegal case, we emphasized some clinical criteria to make a prompt diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.

Trauma Team Activation at a Level I Trauma Center in Southern California: Time of Day Matters

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC+USC (January 2008-July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23-53]. The median Injury Severity Score was 4 [1-10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND

We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients.

METHODS

We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated.

RESULTS

Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis).

CONCLUSION

Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary.

SUMMARY

For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.

Lung Hernia Related with a Rope Bullfight: Case Report

Lung herniation is an uncommon entity which was fully classified in 1845 after the study of several case reports. Acquired lung hernia, especially traumatic, is the most common etiology. In the absence of clear guidelines, management of lung hernia is made in a case-by-case basis. We present an asymptomatic middle lobe hernia perceptible on physical examination, but diagnosed initially by imaging studies. Patient medical history included a blunt bull trauma fourteen years before.

Large Traumatic Retinal Dialysis Associated With Prominent Vitreous Base Avulsion

A 13-year-old female with a history of regressed retinopathy of prematurity presented with new-onset floaters after sustaining blunt force trauma to her left eye. Best-corrected visual acuity was 20/20 in both eyes (OU), with an intraocular pressure of 14 mm Hg and 15 mm Hg in the right eye (OD) and left eye (OS), respectively. Exam under anesthesia revealed an unremarkable anterior segment OU, including no hyphema or subluxated crystalline lens. Scleral depression OS demonstrated a retinal dialysis superotemporally (1-o'clock to 3-o'clock) and nasally (7-o'clock to 10-o'clock) associated with a prominent vitreous base avulsion but no subretinal fluid (Figure). Scleral depression OD was unremarkable. Both areas of retinal dialysis OS were treated with three rows of indirect green laser photocoagulation posterior to the edge of the dialysis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:731.].

Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib

We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.

"Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature

We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.

[Firework injuries in the south-western region of the Netherlands around the turn of the year 2017-2018]

OBJECTIVE

To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries.

DESIGN

A prospective multicentre cohort study (NTR6793).

METHODS

Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews.

RESULTS

Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries.

CONCLUSION

Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicates that the study findings can be extrapolated to the rest of the Netherlands.

Blunt Trauma-Induced Pericardial Tamponade After Video-Assisted Thoracoscopic Surgery

This report describes a case of blunt cardiac injury and pericardial tamponade after video-assisted thoracoscopic surgery in a patient with lung cancer, hypertension, and cardiac hypertrophy. Anatomic findings included massive hemorrhage in the pericardium, cardiac hypertrophy, and a superficial contusion with a ruptured blood vessel on the epicardium at the lateral wall of the left ventricle. The patient died of pericardial tamponade secondary to blunt trauma from the tip of the thoracoscopic instrument. This case suggests that detailed assessment of the cardiovascular system, especially cardiac hypertrophy, careful preoperative preparation, and careful monitoring of postoperative conditions are important.

Pediatric renal injury: which injury grades warrant close follow-up

PURPOSE

Most children who suffer renal trauma recover fully; however, some have long-term consequences. We sought to determine what grades of injury carry concern for complication and warrant close follow-up.

METHODS

Data on children with grade II or higher renal injuries from a single center over 20 years were reviewed. Demographics, presenting symptoms, lab values, clinical course, management, and follow-up data were analyzed.

RESULTS

One hundred seventy-one children suffered renal injuries: 75% boys, aged 11.6 ± 3.5 years. Falls-54 and sports-43 were leading injury mechanisms. Presentations included pain only-61, pain and hematuria-28 and hematuria alone-11. Eight had pre-existing abnormalities. Injury grades were: grade II-88 (52%), grade III-49 (29%), grade IV-28 (16%), and grade V-6 (3%). No grades II or III patient underwent intervention or suffered sequelae. Grade IV patients underwent: stenting-5, surgery-2, embolization-1, and drainage-1. Grade V patients underwent: surgery-2, embolization-1, and drain-1. Two grade IV patients underwent late interventions: nephrectomy-1 and stenting-1. Six patients, all grades IV-V, were newly hypertensive at follow-up.

CONCLUSION

Grades II and III renal injuries carry a low risk of complication and repeat imaging and close follow-up are likely not necessary. However, grades IV and V injuries carry a meaningful risk of adverse outcome and close follow-up is warranted.

Diagnosing and managing common genital emergencies in pediatric girls

The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.

Is a "Pan-Scan" Indicated in the Older Patient with a Ground Level Fall?

Routine full-body CT "pan-scan" use in older patients after ground level falls (GLFs) is of questionable benefit. Retrospective review of new diagnosis & changes in management in patients >55 years with Glasgow Coma Scale of 15 after a GLF who received a pan-scan (routine head, cervical spine/neck, chest abdomen, and pelvis CT). Head CT results were considered separately; results described in the following paragraph pertains to cervical spine/neck, chest, abdomen, and pelvis CT. One hundred and fifty-two patients received pan-scans; 96 (63%) had new findings. Thirty-five (23%) resulted in a minor change and three (2%) in a major change in management, defined as a procedural intervention. This included tube thoracostomy in one patient and cervical spine surgery in two. A further eight patients required the use of a cervical collar. In all patients requiring intervention, there were clinical signs present that should have led to directed CT scan of area of concern. Routine pan-scans in stable, alert older patients after a GLF result in new findings in most patients, with primarily nonprocedural interventions for these additional findings.

Postdischarge Mortality after Geriatric Low-Level Falls: A Five-Year Analysis

Geriatric trauma patients with low-level falls often have multiple comorbidities and limited physiologic reserve. Our aim was to investigate postdischarge mortality in this population. We hypothesized that five-year mortality would be higher relative to other blunt mechanisms. The registry of our Level 1 trauma center was queried for patients evaluated between July 2008 and December 2012. Adult patients identified were matched with mortality data from 2008 to 2013 from the National Death Index. Low-level falls were identified by E Codes; other types of blunt trauma were based on registry classification. Patients with multiple admissions were excluded. Univariate analysis was performed using Fisher's exact and Wilcoxon tests. Kaplan-Meier curves were plotted to compare postdischarge mortality. Seven thousand nine hundred sixteen patients were evaluated, 35.1 per cent were females. Patients aged less than 65 years and penetrating trauma were excluded, yielding 1997 patients-63.7 per cent with low-level falls versus 36.3 per cent with other blunt traumas. Geriatric patients sustaining low-level falls were older, more likely female, had a higher inpatient mortality, and were less likely to return home at discharge. Injury severity score, hospital length of stay, and intensive care unit length of stay were similar. Survival analysis demonstrated increased postdischarge mortality in the low-level fall group with 25 per cent mortality at 120 days. Geriatric patients with other blunt trauma had a significantly lower postdischarge mortality. Geriatric patients injured in low-level falls have a higher inhospital mortality, are more likely to be functionally dependent on discharge, and have a high postdischarge mortality. Opportunities likely exist for injury prevention, consideration of palliative care, and postdischarge rehabilitation.

Acute myocardial infarction after blunt chest wall trauma with underlying coronary aneurysm: a case report

BACKGROUND

Kawasaki disease is an acute febrile disease with mucocutaneous and cardiovascular involvement affecting infants and young children. Though coronary artery abnormalities are common in Kawasaki disease, no consensus has been reached regarding the treatment of acute coronary artery diseases in this population.

CASE PRESENTATION

We described a case of myocardial infarction triggered by blunt chest wall trauma in a 20 years old girl. She presented with chest pain and breathlessness with brief syncope, lab results and electrocardiogram findings were consistent with acute myocardial infarction. Chest computer tomography (CT) demonstrated coronary artery calcifications and echocardiography revealed multiple giant left anterior descending aneurysms, suggestive of Kawasaki disease. Subsequent contrast enhanced 3 dimensional coronary computer tomography angiography (CTA) confirmed these findings. We managed this young patient with a conservative strategy. The patient remained symptom free during 2-years follow-ups.

CONCLUSIONS

Prompt medical treatment for traumatic myocardial infarction even with underlying giant coronary artery aneurysms can successfully preserve left ventricular function and prevent remodeling with good short term prognosis.

Blunt abdominal trauma following gunshot wound Case report and literature review

Blunt abdominal trauma following gunshot wound. Case report and literature review Introduction: Similarly to blast weapons, every firearm produces explosion at the moment of shooting, which can cause injuries in every region of the body. The aim of this paper is to present the mechanism of blunt abdominal injury following gunshot wounds, bringing this uncommon disease to the clinicians' attention and to review the literature available.

CASE REPORT

A patient developed a delayed bowel perforation following a gunshot injury of the abdomen without breaking of the peritoneum. It was clinically suspected eight hours later and confirmed with contrast-enhanced computed tomography scan. The patient underwent immediate laparotomy. Resection, end-to-end anastomosis, and large lavage of the peritoneal cavity was performed. The patient was discharged ten days after operation in good condition.

CONCLUSION

Failure to recognize blunt trauma mechanism following firearm wounds increases the risk of missed injuries. Distant injuries should be suspected in all cases after blast wave and firearms exposure and a follow up should be done for many days to make sure such injuries are excluded. CT scan total body is recommended in all such cases. Key words: Blunt trauma, Distant Injuries, Firearm injuries, Pressure Waves.

[Hemothorax - a conservative approach in a patient with multiple comorbidities]

The authors present the case of an elderly woman with multiple comorbidities hospitalized with the diagnosis of community- acquired pneumonia with pleural effusion. However, there was a history of fall with chest trauma 1 week before, coinciding with the onset of symptoms. The patient had a massive hemothorax that could not be drained. There was a progressive worsening of the patient clinical status with sustained fever and arising of inflammatory parameters, despite broad-spectrum antibiotic therapy and antipyretics. The case was discussed in a multidisciplinary team, and the possibility of surgical intervention was rejected. As life-saving therapy, it was decided to perform fibrinolysis with tissue plasminogen activator, through the thoracic drain, which occurred successfully and without complications. The hemothorax was drained completely allowing recovery of the patient.

Long-Term Functional Outcomes after Traumatic Thoracic and Lumbar Spine Fractures

The incidence of thoracolumbar spine fractures in blunt trauma is 4 to 5 per cent. These fractures may lead to neurologic injury, chronic back pain, and disability. Most studies from United States trauma centers focus on neurologic sequelae and/or compare treatment modalities. However, most patients with spine fractures do not have a neurologic deficit. Our primary objective was to determine the long-term outcome of traumatic thoracolumbar spine fractures, specifically addressing quality of life, chronic pain, and employment using a validated patient outcome survey. A chart review of 138 adult blunt trauma patients who sustained a thoracolumbar spine fracture and were admitted to our Level I trauma center from 2008 to 2013 was performed. A phone interview based on the Short-Form 12®, a general health survey, was then conducted. Of the 134 patients who met the inclusion criteria, 46 (34%) completed the survey. The average Short-Form 12® scores were 51.0 for the physical health component score and 52.9 for the mental health component score. These did not differ significantly from the national norm. Furthermore, 83 per cent (38) of the survey respondents returned to work full-time at the same level as before their injury. Majority of the patients (76%) said they did not have pain two to seven years after injury. Despite a commonly held belief that back injury leads to chronic pain and disability, after sustaining a thoracic or lumbar fracture, patients are generally able to return to work and have a comparable quality of life to the general population. This knowledge may be useful in counseling patients regarding expectations for recovery from trauma.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Left Internal Thoracic Artery Graft to Left Anterior Descending Coronary Artery after Blunt-Chest-Trauma Myocardial Infarction: 14-Year Outcome

In 2005, we reported an acute myocardial infarction secondary to a left anterior descending coronary artery injury sustained in a motorcycle accident. The treatment was late myocardial revascularization with in situ left internal thoracic artery-to-left anterior descending coronary artery anastomosis. There is little information available about the natural history of acute myocardial infarction after blunt chest trauma, especially when treated in this manner. This present communication reports the 14-year outcome in our patient.