1
|
Sciarretta JD, Noorbakhsh S, Joung Y, Bailey DW, Freedberg M, Nguyen J, Smith RN, Ayoung-Chee P, Davis MA, Benjamin ER, Todd SR. Pneumopericardium following severe thoracic trauma. Injury 2024; 55:111303. [PMID: 38218676 PMCID: PMC11023791 DOI: 10.1016/j.injury.2023.111303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/24/2023] [Accepted: 12/23/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Traumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication. Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury. METHODS We conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management. RESULTS Over a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18-77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC. CONCLUSIONS Traumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.
Collapse
Affiliation(s)
- Jason D Sciarretta
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Soroosh Noorbakhsh
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US.
| | - Yoo Joung
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US
| | - Daniel W Bailey
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Mari Freedberg
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Jonathan Nguyen
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Randi N Smith
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Patricia Ayoung-Chee
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Millard A Davis
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Elizabeth R Benjamin
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - S Rob Todd
- Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| |
Collapse
|
2
|
Castater C, Bishop E, Santos A, Freedberg M, Kim P, Sciarretta C. Diabetic Soft Tissue Infections. Surg Clin North Am 2023; 103:1191-1216. [PMID: 37838463 DOI: 10.1016/j.suc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Diabetes is a systemic illness that can cause a broad range of physiologic effects. Infection rates and wound healing are both affected through multiple mechanisms. Other physiologic changes increase risk for wounds as well as complex soft tissue infections ranging from simple cellulitis to necrotizing soft tissue infections. Clinicians and surgeons need to have a low index of suspicion for severe infection in a patient presenting with diabetes, and even more so in patients with uncontrolled diabetes.
Collapse
Affiliation(s)
- Christine Castater
- Morehouse School of Medicine, Grady Memorial Hospital 1C-144, 80 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
| | - Elliot Bishop
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Adora Santos
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Mari Freedberg
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Phillip Kim
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Christopher Sciarretta
- University of Tennessee, University of Tennessee College of Medicine, 975 3rd Avenue, Chattanooga, TN 37403, USA
| |
Collapse
|
3
|
Noorbakhsh S, Gomez L, Joung Y, Meyer C, Hanos DS, Freedberg M, Klingensmith N, Grant AA, Koganti D, Nguyen J, Smith RN, Sciarretta JD. Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature. Vasc Endovascular Surg 2023; 57:749-755. [PMID: 36940466 PMCID: PMC10724846 DOI: 10.1177/15385744231165155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
PURPOSE Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. METHODS One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. RESULTS Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. CONCLUSION Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.
Collapse
Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Lissette Gomez
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Yoo Joung
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Courtney Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dustin S. Hanos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Mari Freedberg
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan Klingensmith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - April A. Grant
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| |
Collapse
|
4
|
Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
Collapse
Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| |
Collapse
|
5
|
Abstract
The conditions required for isolation of ribosomal particles from guinea-pig epidermis and half-root cells have been studied. Density-gradient patterns of the ribosomes following isolation from either tissue under a wide variety of conditions are essentially the same. Monomeric ribosomes are the predominant species isolable although polymeric ribosomes and subunits can be identified. The density-gradient pattern is not related to runoff during preparation. Detergent extraction is required for maximal recovery of particles from epidermis or wax-epilated hair roots even without detergent. The yield of ribosomes from both epidermis and hair roots is greatest in buffers with potassium concentrations between 100 and 250mM. Yield is decreased in buffers with magnesium concentrations above 5mM. Activity in an in vitro amino acid-incorporating system is unaffected by potassium concentration and is highest at magnesium concentration of 3mM. Activity of epidermal ribosomes is inhibited by the wax-epilation method while hair root-cell ribosomes are equally active following preparation with either latex or wax. The isolated ribosomal particles are unstable at 4 degrees C.
Collapse
|