Endovascular management of lap belt-related abdominal aortic injury in a 9-year-old child

Blunt abdominal aortic trauma is a rare occurrence in children with only a few patients having been reported in the literature. Most such cases have been described in the context of lap belt injuries. We report a 9-year-old boy who suffered lap belt trauma to the abdomen during a high-speed road traffic accident resulting to the well-recognized pattern of blunt abdominal injury, that is, the triad of intestinal perforation, fractures of the lumbar spine, and abdominal aortic injury. The latter presented with lower limb ischemia due to dissection of the infrarenal aorta and right common iliac artery. Revascularization was achieved by endovascular means using 2 self-expanding stents in the infrarenal aorta and the right common iliac artery. This case is one of the few reports of lap belt-related acute traumatic abdominal aortic dissection in a young child and highlights the feasibility of endovascular management in the pediatric population.

[Injuries from violence in young children--signs, management and diagnostics]

Inflicted injuries in infants and toddlers may easily be missed unless clinicians who care for children are alert to sometimes subtle clues in the history and physical exam. Any injury which is unexplained or incompatible with the developmental capabilities of the child or inconsistent with the given history should prompt a medical evaluation for suspected physical abuse. The most common cause of serious head injuries in infants younger than 12 months is child abuse. Shaking and blunt head trauma can result in injuries such as subdural hemorrhage, diffuse retinal hemorrhage, and brain and spine injury. Early detection of child physical abuse requires a systematic and careful diagnostic approach. The physician must be able to recognize suspicious injuries, as well as possess an understanding of the mimics that may be confused with inflicted injuries. Health care professionals are mandated by Swedish law to promptly report suspected abuse to child protective services.

Animal attack: an unusual case of multiple trauma in childhood

A 2½ year old girl attended our facility following attack by a tapir at a city zoo. She sustained multiple injuries including a forearm laceration and multiple perforating wounds to her abdominal wall. She had several procedures, including bowel resection, performed under the care of the General Paediatric Surgery and Plastic Surgery teams and was treated with a course of IV antibiotics. She recovered well and to date has suffered no long-term adverse outcome.

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips (OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy.

Unsuspected serious abdominal trauma after falls among community-dwelling older adults

BACKGROUND

In elderly community-dwelling patients who experience ground-level falls, fractures or brain injury are the major concern. Serious abdominal injury is seldom contemplated.

AIM

Identify all such patients presenting after a simple fall and admitted with serious blunt abdominal trauma to a single academic medical centre.

DESIGN

Retrospective chart analysis.

METHOD

All patients with both diagnoses aged 65 years or more admitted over 1 year to the department of medicine, geriatrics, surgery or urology were identified.

RESULTS

Out of 546 patients screened, three cases of ground-level falls leading to splenic rupture, isolated gallbladder rupture with gallstone ileus and perinephric hematoma were found (0.55%) and are reported.

CONCLUSIONS

Falls in elderly patients are exceedingly common mandating recognition of even rare complications. Physicians should be more aware of the possibility of occult and serious consequences of blunt abdominal trauma after falls among older adults, albeit rare.

Seat belt syndrome, a new pattern of injury in developing countries. Case report and review of literature*

BACKGROUND

Classically, seat belt syndrome appears with seat belt marks on the body, bowel perforations, and lumbar spine fractures. However the symptoms are not limited to those previously mentioned, and organ damage can vary greatly.

CASE REPORT

A 34-year-old female passenger, was admitted to our hospital after a motor vehicle crash. The physical examination revealed an ecchymosis across the chest, a transverse abdominal abrasion, and fractures of the left humerus, the left femur, and the right tibia. The laparotomy revealed multiple jejunal perforations, such as a seromuscular tear of the hepatic and splenic flexure of the colon and a defect of the abdominal wall. The primary suture of jejunum, resection with end to end anastomosis of jejunum, suture of a seromuscular tear of the colon, and primary repair of the abdominal wall defect procedures were performed. On the fifth day, the patient underwent osteosynthesis.

CONCLUSION

The abdominal pain in the polytraumatized patients with seat belt syndrome may be dominated by the pain caused by extra-abdominal injuries. The presence of a seat belt mark across the abdomen increases suspicion of abdominal injuries.

The full spectrum of handlebar injuries in children: a decade of experience

BACKGROUND

Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI.

METHODS

Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI.

RESULTS

1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively.

CONCLUSIONS

Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.

Injury prediction in a side impact crash using human body model simulation

BACKGROUND

Improved understanding of the occupant loading conditions in real world crashes is critical for injury prevention and new vehicle design. The purpose of this study was to develop a robust methodology to reconstruct injuries sustained in real world crashes using vehicle and human body finite element models.

METHODS

A real world near-side impact crash was selected from the Crash Injury Research and Engineering Network (CIREN) database. An average sedan was struck at approximately the B-pillar with a 290 degree principal direction of force by a lightweight pickup truck, resulting in a maximum crush of 45 cm and a crash reconstruction derived Delta-V of 28 kph. The belted 73-year-old midsized female driver sustained severe thoracic injuries, serious brain injuries, moderate abdominal injuries, and no pelvic injury. Vehicle finite element models were selected to reconstruct the crash. The bullet vehicle parameters were heuristically optimized to match the crush profile of the simulated struck vehicle and the case vehicle. The Total Human Model for Safety (THUMS) midsized male finite element model of the human body was used to represent the case occupant and reconstruct her injuries using the head injury criterion (HIC), half deflection, thoracic trauma index (TTI), and pelvic force to predict injury risk. A variation study was conducted to evaluate the robustness of the injury predictions by varying the bullet vehicle parameters.

RESULTS

The THUMS thoracic injury metrics resulted in a calculated risk exceeding 90% for AIS3+ injuries and 70% risk of AIS4+ injuries, consistent with her thoracic injury outcome. The THUMS model predicted seven rib fractures compared to the case occupant's 11 rib fractures, which are both AIS3 injuries. The pelvic injury risk for AIS2+ and AIS3+ injuries were 37% and 2.6%, respectively, consistent with the absence of pelvic injury. The THUMS injury prediction metrics were most sensitive to bullet vehicle location. The maximum 95% confidence interval width for the mean injury metrics was only 5% demonstrating high confidence in the THUMS injury prediction.

CONCLUSIONS

This study demonstrates a variation study methodology in which human body models can be reliably used to robustly predict injury probability consistent with real world crash injury outcome.

The ins and outs of terrorist bus explosions: injury profiles of on-board explosions versus explosions occurring adjacent to a bus

BACKGROUND

Terrorist explosions occurring in varying settings have been shown to lead to significantly different injury patterns among the victims, with more severe injuries generally arising in confined space attacks. Increasing numbers of terrorist attacks have been targeted at civilian buses, yet most studies focus on events in which the bomb was detonated within the bus. This study focuses on the injury patterns and hospital utilisation among casualties from explosive terrorist bus attacks with the bomb detonated either within a bus or adjacent to a bus.

METHODS

All patients hospitalised at six level I trauma centres and four large regional trauma centres following terrorist explosions that occurred in and adjacent to buses in Israel between November 2000 and August 2004 were reviewed. Injury severity scores (ISS) were used to assess severity. Hospital utilisation data included length of hospital stay, surgical procedures performed, and intensive care unit (ICU) admission.

RESULTS

The study included 262 victims of 22 terrorist attacks targeted at civilian bus passengers and drivers; 171 victims were injured by an explosion within a bus (IB), and 91 were injured by an explosion adjacent to a bus (AB). Significant differences were noted between the groups, with the IB population having higher ISS scores, more primary blast injury, more urgent surgical procedures performed, and greater ICU utilisation. Both groups had percentages of nearly 20% for burn injury, had high percentages of injuries to the head/neck, and high percentages of surgical wound and burn care.

CONCLUSIONS

Explosive terrorist attacks detonated within a bus generate more severe injuries among the casualties and require more urgent surgical and intensive level care than attacks occurring adjacent to a bus. The comparison and description of the outcomes to these terrorist attacks should aid in the preparation and response to such devastating events.

Pretensioner loading to rear-seat occupants during static and dynamic testing

OBJECTIVE

Pretensioners reduce the seat belt slack and couple the occupant early to the restraint system. There is a growing prevalence of rear seat pretensioners and it is essential to determine whether the load from the pretensioner itself can cause injuries to rear-seated children. The aim of the study was to investigate the loading to the neck, chest, and abdomen of various sizes of anthropometric test devices (ATDs) during the pretensioner deployment phase and the crash phase in low-severity frontal sled tests and during static deployment.

METHODS

Low-severity frontal sled tests were conducted with the Hybrid III (HIII) 3-year-old, HIII 6-year-old, HIII 5th percentile, and HIII 50th percentile ATDs. Two different retractor pretensioners with varying pretensioner force were used. The child ATDs were restrained on a booster cushion (BC), with and without a back. The loading to the neck and chest was compared to injury assessment reference values (IARVs) reported by Mertz et al. (2003). The chest loading to the HIII 5th percentile and HIII 50th percentile ATDs was also analyzed using age-related injury risk curves. Static pretensioner tests with the Q-series 10-year-old ATD, equipped with an advanced abdominal loading device, were conducted in standard ATD position and out-of-position with the lap belt positioned high on the abdomen.

RESULTS

During the crash phase, head excursion and neck loading were reduced for both pretensioners for all ATDs compared to testing without a pretensioner. The pretensioner reduced chest deflection to the adult ATDs but not to child ATDs when seated on a BC with a back during the crash phase. When the back was removed, chest deflection was reduced below IARV. The head excursion was reduced for all ATDs with both pretensioners. During the pretensioner deployment phase, the chest deflection exceeded the IARV for the HIII 3-year-old with the stronger pretensioner when seated on booster with a back and it was reduced below the IARV with the lower force pretensioner. For all ATDs, neck and chest loading during the pretensioner deployment phase were reduced when a pretensioner with lower force was used. Abdominal loading to the Q10 in the static pretensioner deployments indicated a low risk of abdominal injury in all tested positions.

CONCLUSION

This study indicates the need to balance the pretensioner force and seat belt geometry to gain good pretensioner performance in both the pretensioner deployment phase and the crash phase.

The utility of the predictive scores in polytrauma with abdomino-pelvic injuries: a series of 38 patients

Trauma is the principal cause of mortality among the population under 40 years. The aim of our study was to compare predictive trauma scores and demonstrate their utility in the evaluation of the quality of care in polytrauma.

MATERIAL AND METHODS

A retrospective study was performed between 2000-2011 including polytrauma patients with abdominal lesions and pelvic fracture who under went emergency laparotomy. We calculated ISS, GCS, RTS,TRISS, ASCOT trauma scores and W score for evaluation of treatment quality.

RESULTS

We obtained the necessary data to calculate the predictive scores in 38 cases. Comparing the scores of the survivals and non-survivals we noted the following regarding mortality predictive scores: GCS 13.74 vs. 6.13 (p 0.0001),ISS 28.52 vs. 35 (p=0.0169), RTS 6.96 vs. 3.07 (p 0.0001),TRISS 84.67% vs. 28.7% (p 0.0001), ASCOT 10.34% vs.64.32% (p 0.0001). The W score in TRISS and ASCOT methodology was -2.05 (p=0.7997) and -7.81 (p=0.336),respectively. There was no statistically significant difference between actual and predicted mortality, the former being 39.47%.

CONCLUSION

We did not observe differences between the two methodologies TRISS and ASCOT in mortality prediction (p=0.5401). Both of them can be used to predict polytrauma patient evolution. The W score is useful in treatment quality assessment.

Paediatric femoral shaft fractures: what are the concomitant injuries?

INTRODUCTION

Trauma remains a substantial cause of paediatric morbidity and mortality. Femur fractures are common in children, and frequently are the result of high-energy mechanisms of injury. A complete description of missed injuries in this population has not previously been described.

MATERIALS AND METHODS

A retrospective chart review of patients presenting to the Alberta Children's Hospital with femoral shaft fractures was performed. Associated injuries, and injuries with delayed diagnosis were recorded.

RESULTS

Twenty-percent of the patients suffered at least one other injury with their femur fracture. Six-percent of injuries had a delayed diagnosis, corresponding to three-percent of the patients reviewed.

CONCLUSION

There is a risk of missed injuries in the paediatric patient presenting with a femoral shaft fracture. Paediatric trauma teams and paediatric orthopaedic teams must be aware of this risk to help reduce the incidence of missed injuries. A tertiary trauma survey on children with paediatric femoral shaft fractures may help diagnose missed injuries.

Traumatic pancreatic injury--an elusive diagnosis: experience from a developing country urban trauma referral centre

OBJECTIVE

To determine the frequency of pancreatic injury in patients presenting with trauma and to review the mechanism of injury, management, subsequent complications and in-hospital mortality rate associated with these patients.

METHODS

The retrospective study included all patients over 18 years of age presenting with pancreatic injury due to trauma at the Aga Khan University Hospital, Karachi, between January 1990 and December 2009. Patients with iatrogenic pancreatic injury were excluded. The severity of the injury was assessed using the Injury Severity Score, while it was graded according to the scale defined by the American Association for the Surgery of Trauma. SPSS 17 was used for statistical analysis.

RESULTS

A total of 30 patients were identified representing just 1.5% of the total adult abdominal trauma patients. The mean age of the patients was 28 +/- 9.7 years. There were 28 (93.3%) males and just 2 (6.6%) females. The complication rate was 80% (n = 24) and the mortality rate was 23.3% (n = 7). Of the 30 patients, 19 (63%) had been transferred from some other medical facility.The mean length of hospital stay was 16.4 +/- 20.6 days (range 5-97 days).

CONCLUSION

Surgical management in pancreatic trauma patients should be dictated by the degree and location of pancreatic injury, associated injuries and time from event to presentation. Mortality was primarily determined by associated life-threatening injuries.

Isolated pediatric pancreatic transection secondary to ocean-related trauma

CONTEXT

Isolated pancreatic transection is a rare but well-recognized complication following blunt trauma of the abdomen. Diagnosis at presentation may be difficult and delayed due to subtle initial symptoms and evolving nature of the injury.

CASE REPORT

We describe an isolated complete pancreatic transection in a 14-year-old female secondary to a previously unreported and highly unusual mechanism (being tossed by a wave). Diagnosis was obtained by computed tomography scan 24 hours following initial trauma. She was managed operatively with an open distal pancreatectomy with splenic preservation and no subsequent complications.

CONCLUSIONS

The force sustained from the blunt abdominal trauma of being tossed by a wave can be significant. The management of pancreatic injuries in children, particularly in the context of ductal transection, is controversial. Timely recognition and management is critical to optimal outcomes. Early operative intervention may help to avoid complications such as abscess or pseudocyst formation.

[Treatment of patients with suicidal and autoagressive neck, thorax and abdomen injuries]

The issue is devoted to the analysis of case reports of 305 patients with suicidal and autoagressive neck, thorax and abdomen injuries. The objective prevalence of penetrating injuries of the abdomen among men with depressive disorders was registered. The most complicated, both for surgeon and psychiatrist, were cases of combined neck, thorax and abdomen injuries in elderly patients.

[The Morel-Lavallée-lesion: delayed symptoms after trauma]

BACKGROUND

The Morel-Lavallée lesion is a post-traumatic collection of fluid arising after a 'closed degloving injury' has caused the separation of the skin and subcutis from the underlying muscular fascia. It usually occurs in the trochanteric region or proximal thigh.

CASE DESCRIPTION

A 36-year-old obese man was referred to the emergency department by his general practitioner for fever and pain in the right lower abdominal quadrant. Blood testing revealed elevated infection parameters. As appendicitis was suspected, a CT scan of the abdomen was performed. This revealed a Morel-Lavallée lesion, which he had sustained 9 months earlier when he had been hit by a car while riding his bicycle. A rapid recovery ensued after ultrasound-guided percutaneous drainage and treatment with antibiotics.

CONCLUSION

A Morel-Lavallée lesion, which could manifest even months later, should be considered after any traumatic injury. Ultrasound, CT and MRI are useful tools for proper diagnosis. There is no consensus about treatment in either the acute or the chronic phase to date.

[The general characteristic of abdominal injuries inflicted by a blow of an unarmed man]

The experience gained in the course of the many-year forensic medical practice as regards abdominal injuries caused by a blow of an unarmed man is described. The data on the occurrence and frequency of different variants of such injuries are presented. Their morphological features are considered in much detail. The relationship between the nature of the injurious factor (the part of the human body with which a given injury was inflicted) and the character of the traumas. It is concluded that these data should be taken into account when resolving forensic medical problems related to the possibility of formation of an abdominal injury inflicted by a blow of an unarmed man.

Renal trauma from recreational accidents manifests different injury patterns than urban renal trauma

PURPOSE

The majority of blunt renal trauma is a consequence of motor vehicle collisions and falls. Prior publications based on urban series have shown that significant renal injuries are almost always accompanied by gross hematuria alone or microscopic hematuria with concomitant hypotension. We present a series of blunt renal trauma sustained during recreational pursuits, and describe the mechanisms, injury patterns and management.

MATERIALS AND METHODS

Database review from 1996 to 2009 identified 145 renal injuries. Children younger than age 16 years, and trauma involving licensable motor vehicles, penetrating injuries and work related injuries were excluded from analysis. Grade, hematuria, hypotension, age, gender, laterality, mechanism, management, injury severity score and associated injuries were recorded.

RESULTS

We identified 106 patients meeting the criteria and 85% of the injuries were snow sport related. Age range was 16 to 76 years and 92.5% of patients were male. There were 39 grade 1 injuries, 30 grade 2, 22 grade 3, 12 grade 4 and 3 grade 5 injuries. Gross hematuria was present in 56.7%, 77.2% and 83.3% of grade 2, grade 3 and grade 4 injuries, respectively. None of the patients with grade 2 or greater injuries and microscopic hematuria had hypotension except 1 grade 5 pedicle injury. The nephrectomy and renorrhaphy rate for grade 1 to grade 4 injuries was 0%.

CONCLUSIONS

Compared to urban series of blunt renal trauma, recreationally acquired injuries appear to follow different patterns, including a paucity of associated injuries or hypotension. If imaging were limited to the presence of gross hematuria, or microscopic hematuria with hypotension, 23% of grade 2 to grade 4 injuries would be missed. Men are at higher risk than women. However, operative intervention is rarely helpful.

Surgical management in parenchymatous organ injuries due to blunt and penetrating abdominal traumas--the authors' experience

BACKGROUND

Social developments have brought increases in both motorization and violence worldwide, including in Poland, which has meant a steady increase in the percentage of multi-organ injuries, including abdominal, spleen and liver injuries. As a result of these injuries, the number of deaths from hemorrhagic shock is constantly growing.

MATERIAL AND METHODS

The study presents 126 patients hospitalized after blunt and penetrating abdominal parenchymatous organ traumas over a 10-year period (2000-2010).

RESULTS

The majority of parenchymatous organ traumas in the study period resulted from traffic accidents. The examined group included cases of liver injury, spleen injury and simultaneous liver and spleen damage. Among liver and spleen injuries, the most frequent was parenchymal rupture. A variety of surgical procedures were applied, including laparoscopy used as both a diagnostic and therapeutic method. Among the 126 patients hospitalized after parenchymatous organ traumas, nine died.

CONCLUSIONS

Parenchymatous organ injuries after abdominal traumas are a very important surgical issue nowadays. Laparoscopy is increasingly frequently applied both as a diagnostic and therapeutic and technique. Due to the accessibility of highly specialized imaging diagnostics, observation and conservative treatment in spleen injuries is now possible.

[Disputable issues of a gun shot thoracoabdominal injury in tangential wounding]

Experience of a specialized aid practice in thoracoabdominal shearing woundings was summarized. The authors suggest, that tangential, or shearing, woundings occupy rather small place in actual classification of thoracoabdominal woundings. The authors propose classification of their own of such woundings and algorithm of diagnosis and treatment in wounded persons, what would permit to improve the quality of a specialized aid delivery to such patients.

NOTES: 'pre-dilatation' as a remedy for technical issues during transgastric access

OBJECTIVE

To identify and resolve procedural issues during transgastric access for the Natural Orifice Translumenal Endoscopic Surgery (NOTES), where feasibility and safety is established in animals and humans. However, several technical problems during viscerotomy result in considerable delay or procedure failure.

METHODS

Gastrotomy was performed under general anaesthesia in survival canine models. Single channel (adult) colonoscope was used. Anterior gastric wall was punctured in mid corpus region with needle knife method and percutaneous endoscopic gastrotomy (PEG) technique in separate dogs. Post-operatively, animal was observed for 2 weeks but it was immediately sacrifised if the creation of viscerotomy had failed. Postmortem examination of these animals focused on the cause of failure and detection of visceral injury. On account of frequent complications, needle knife method was replaced with percutaneous endoscopic gastrotomy technique. Visceral aperture was successfully accomplished with over-the-wire (OTW) balloon dilators after 'pre-dilatation' of the primary puncture with over-the-wire plastic bougies.

RESULTS

Gastrotomy was performed in dogs (23) using two methods: needle knife (4) and PEG (19). Initially, there were 5 failures: needle knife (3); PEG (2). The failures resulted from organ damage (2) and inability to insert over-the-wire balloon dilator into gastric puncture (3). The needle knife method was abandoned due to major complications in 4 animals: gastric bleeding (2); liver rupture (1); penetrating injury to anterior abdominal wall (1). Viscerotomy was achieved in (17) consecutive cases by 'pre-dilating' the site of initial puncture. There was no mortality.

CONCLUSION

'Pre-dilatation' with over-the-wire plastic dilators is recommended for the creation of gastrotomy.