Hepatic Angioembolization in Trauma Patients: Indications and Complications.

BACKGROUND: Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS: A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS: Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION: HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently

Characterization of angiotensin pressor responses in the turtle Pseudemys scripta.

Studies were conducted in turtles (Pseudemys scripta) to characterize vascular responses to administration of exogenous angiotensin [Asp1-Ile5]angiotensin II (AII). Marked pressor responses were present following AII administration (2 microgram/kg iv). The pressor response was completely blocked by concomitant administration of an analogue of AII, [Sar1-Ile8]AII. Both alpha-receptor blockade with phenoxybenzamine or catecholamine depletion by reserpine administration reduced the pressor response approximately 50%. Further treatment with [Sar1-Ile8]AII completely blocked the AII pressor response. We conclude that the pressor response to AII in this species that represents an ancient group of reptiles includes a catecholamine-dependent component and direct vascular receptors, both of which are sensitive to AII

Fracture of the humeral neck with intrathoracic dislocation of the humeral head.

Intrathoracic fracture-dislocation of the humeral neck is a rare and easily overlooked clinical entity. We present a case and review of the literature. The objective of this study was to summarize the clinical presentation of this injury and to provide recommendations for initial diagnostic imaging and management. A 68-year-old man presented to the Emergency Department after a fall onto an abducted arm with moderate respiratory distress, mild left shoulder pain, and palpable crepitus over the shoulder and chest wall. Radiographic examination demonstrated the humeral head to be lying within the left hemithorax, devoid of any attachments to the remaining proximal humerus. After initial stabilization, the patient underwent surgical excision of the humeral head and delayed hemiarthroplasty. Careful attention to radiographic studies is required to recognize this injury. Initial management centers on airway management, adjunctive imaging, and treatment of any associated injuries followed by surgical excision and proximal humeral reconstruction

Secondary organ dysfunction. From clinical perspectives to molecular mediators.

The systemic inflammatory response and progression to secondary organ dysfunction are manifestations of the host\u27s responses to injury. This article outlines the clinical manifestations of this injury-response cascade. The potential roles of cytokines, eicosanoids, platelet-activating factor, nitric oxide, oxygen-free radicals, and the leukocyte-endothelial interaction are explored in some detail. A goal-directed therapy of source control, resuscitation, and metabolic support is reviewed, and new therapies with monoclonal antibodies and immunomodulated nutrition are described. These new therapies hold great potential for finally improving the outcome of this fatal syndrome

Small-bowel and mesentery injuries in blunt trauma.

BACKGROUND: The purpose of this study was to identify factors that would aid in the diagnosis of small-bowel and mesentery injuries (SBMI) in blunt trauma patients. METHODS: Retrospective review of 15,779 blunt trauma patients admitted to a Level I trauma center between January 1991 and December 1996. RESULTS: A total of 5,303 patients sustained abdominal injuries, 70 of whom had more than 111 SBMI. Seventy-nine percent were victims of motor vehicle collisions. Thirty patients had isolated SBMI and 40 had associated intra-abdominal injuries. Twelve patients arrived with systolic blood pressure \u3c 90 mm Hg, eight of whom died. Mean base deficit was -7.3 +/- 6.3 in 52 patients who had arterial blood gases determined. Fifty-three of 60 patients had hematuria. Sixty-seven patients required laparotomy. Delayed exploration occurred in 15 patients who underwent initial computed tomography but had subsequent changes in physical status. Two of 20 patients had negative diagnostic peritoneal lavage on admission and were eventually explored based on abdominal computed tomographic findings and changes in physical examination. There were 15 deaths. Delay in diagnosis (\u3e12 hours after arrival) occurred in nine patients with no deaths or significant morbidities. Mean Injury Severity Score was 29 +/- 16.7: 43 +/- 17 in nonsurvivors and 25 +/- 14.3 in survivors (p \u3c 0.05). CONCLUSION: The diagnosis of SBMI is often made in the presence of associated intra-abdominal injuries. Isolated SBMI are common, however, and special attention to the mechanism of injury, abdominal examination, presence of hematuria, and significant base deficit should raise suspicion to the possibility of SBMI. Findings on abdominal computed tomography that may suggest SBMI and should prompt further evaluation include free fluid, thickened bowel, and extraluminal air. Because delay in diagnosis does not seem to affect morbidity or mortality, dedication to observation and serial physical examinations will aid in the proper identification of elusive SBMI. Mortality, however, does appear to be related to the presence of hypotension on admission and associated injuries

Early inflammatory response correlates with the severity of injury.

OBJECTIVE: To determine if the early inflammatory response correlates with the severity of injury in a blunt trauma model in rats. DESIGN: Prospective, randomized, controlled trial. SETTING: Research laboratory. SUBJECTS: Male Sprague-Dawley rats, weighing 250 to 400 g. INTERVENTIONS: Twenty-two male Sprague-Dawley rats were divided randomly into single hindlimb fracture, bilateral hindlimb fracture, and no fracture groups. At 90 mins, all animals underwent midline laparotomy and aspiration of blood from the inferior vena cava. Venous blood gas, plasma lactate, and plasma concentrations of tumor necrosis factor (TNF), prostaglandin F(6-keto-PGF1 alpha), and interleukin (IL)-6 were sampled. Statistical analysis was done via one-way analysis of variance and Scheffé post hoc analysis. In a second part of this experiment, the effect of hemorrhage on the release of IL-6 was evaluated. Animals in this group were compared with control and bilateral hindlimb fracture animals, using the Student\u27s t-test. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in venous pH or base deficit among the groups. Oxygen saturation was significantly decreased in the bilateral hindlimb fracture group when compared with the control group. In the hemorrhage plus bilateral fracture group, oxygen saturation was significantly decreased when compared with the bilateral fracture group. lactate concentrations in plasma were increased in both fracture groups as well as the hemorrhaged groups. Plasma TNF concentrations were increased in the injured groups but there was no significant difference between single and bilateral hindlimb fracture groups. The 6-keto-PGF1 alpha concentrations were increased in both of the fracture groups when compared with the control group and there was a significant difference between single and bilateral hindlimb fracture groups. Similarly, circulating IL-6 concentrations were significantly higher in the bilateral fracture group than in the single fracture group; both fracture groups were significantly higher than the control group. Hemorrhaged animals had even higher IL-6 concentrations. CONCLUSIONS: Plasma lactate and TNF concentrations were affected by injury, however their concentrations did not correlate with degree of injury. IL-6 concentrations were increased early postinjury and correlated with severity of injury. The 6-keto-PGF1 alpha concentrations in plasma also correlated with the severity of injury and this phenomenon may represent early endothelial activation which may be the source of IL-6 release

An Analysis of Outcomes After Trauma in Obstetric Patients.

Traumatic injury in obstetric patients has been shown to correlate with adverse fetal outcomes; however, data predates modern resuscitation and imaging techniques. A single center retrospective review was performed analyzing risk factors for obstetric outcomes for pregnant patients seen at a Level 1 Trauma Center from 2010 to 2020. 571 pregnant patients were compared to nonpregnant child-bearing age women. Injury Severity Scores (ISS) were higher in nonpregnant patients (5 vs 0