Treatment of Fournier's Gangrene with Combination of Vacuum-Assisted Closure Therapy, Hyperbaric Oxygen Therapy, and Protective Colostomy

Fournier's gangrene is a rare process which affects soft tissue in the genital and perirectal area. It can also progress to all different stages of sepsis, and abdominal compartment syndrome can be one of its complications. Two patients in septic shock due to Fournier gangrene were admitted to the Intensive Care Unit of Emergency Department. In both cases, infection started from the scrotum and the necrosis quickly involved genitals, perineal, and inguinal regions. Patients were treated with surgical debridement, protective colostomy, hyperbaric oxygen therapy, and broad-spectrum antibacterial chemotherapy. Vacuum-assisted closure (VAC) therapy was applied to the wound with the aim to clean, decontaminate, and avoid abdominal compartmental syndrome development. Both patients survived and were discharged from Intensive Care Unit after hyperbaric oxygen therapy cycles and abdominal closure

Unexpected Hypertensive Pneumothorax after Digestive Upper Endoscopy: A Case Report

We report an unexpected massive left pneumothorax at the end of a digestive upper endoscopy without evidences of perforation or airway over-pressure. The possible air passage through a diaphragmatic failing is discussed

Advanced accident research system based on a medical and engineering data in the metropolitan area of Florence

BACKGROUND: In the metropolitan area of Florence, 62% of major traumas involve powered two wheeler rider and pillion passengers, 10% cyclists, and 7% pedestrians. The urban and extra-urban areas are the most dangerous for the vulnerable road user. In-depth investigations are needed for assessing detailed information on road accidents. This type of study has been very limited in time frame in Italy, and completely absent in the Tuscan region. Consequently a study called “In-depth Study of road Accident in FlorencE” (In-SAFE) has been initiated. METHODS: A network between the Department of Mechanics and Industrial Technologies (University of Florence) and the Intensive Care Unit of the Emergency Department (Careggi Teaching Hospital, Florence) was created with the aim of collecting information about the road accidents. The data collected includes: on-scene data, data coming from examination of the vehicles, kinematics and dynamic crash data, injuries, treatment, and injury mechanisms. Each injury is codified thorough the AIS score, localized by a three-dimensional human body model based on computer tomography slices, and the main scores are calculated. We then associate each injury with its cause and crash technical parameters. Finally, all the information is collected in the In-SAFE database. RESULTS: Patient mean age at the time of the accident was 34.6 years, and 80% were males. The ISS mean is 24.2 (SD 8.7) and the NISS mean is 33.6 (SD 10.5). The main road accident configurations are the “car-to-PTW” (25%) and “pedestrian run over” (17,9%). For the former, the main collision configuration is “head-on crash” (57%). Cyclists and PTW riders-and-pillions-passengers suffer serious injuries (AIS3+) mainly to the head and the thorax. The head (56.4%) and the lower extremities (12.7%) are the most frequently injured pedestrian body regions. CONCLUSIONS: The aim of the project is to create an in-depth road accident study with special focus on the correlation between technical parameters and injuries. An in-depth investigation team was setup and is currently active in the metropolitan area of Florence. Twenty-eight serious road accidents involving twenty-nine ICU patients are studied. PTW users, cyclist and pedestrians are the most frequently involved in metropolitan accidents

Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prospective observational study

BACKGROUND: Continuous monitoring of central venous oxygen saturation (ScvO(2)) has been proposed as a prognostic indicator in several pathological conditions, including cardiac diseases, sepsis, trauma. To our knowledge, no studies have evaluated ScvO(2 )in polytraumatized patients with brain injury so far. Thus, the aim of the present study was to assess the prognostic role of ScvO(2 )monitoring during first 24 hours after trauma in this patients' population. METHODS: This prospective, non-controlled study, carried out between April 2006 and March 2008, was performed in a higher level Trauma Center in Florence (Italy). In the study period, 121 patients affected by major brain injury after major trauma were recruited. Inclusion criteria were: 1. Glasgow Coma Scale (GCS) score ≤ 13; 2. an Injury Severity Score (ISS) ≥ 15. Exclusion criteria included: 1. pregnancy; 2. age < 14 years; 3. isolated head trauma; 4. death within the first 24 hours from the event; 5. the lack of ScvO(2 )monitoring within 2 hours from the trauma. Demographic and clinical data were collected, including Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Simplified Acute Physiologic Score II (SAPS II), Marshall score. The worst values of lactate and ScvO(2 )within the first 24 hours from trauma, ICU length of stay (LOS), and 28-day mortality were recorded. RESULTS: Patients who deceased within 28 days showed higher age (53 ± 16.6 vs 43.8 ± 19.6, P = 0.043), ISS core (39.3 ± 14 vs 30.3 ± 10.1, P < 0.001), AIS score for head/neck (4.5 ± 0.7 vs 3.4 ± 1.2, P = 0.001), SAPS II score (51.3 ± 14.1 vs 42.5 ± 15, P = 0.014), Marshall Score (3.5 ± 0.7 vs 2.3 ± 0.7, P < 0.001) and arterial lactate concentration (3.3 ± 1.8 vs 6.7 ± 4.2, P < 0.001), than survived patients, whereas ScvO(2 )resulted significantly lower (66.7% ± 11.9 vs 70.1% ± 8.9 vs, respectively; P = 0.046). Patients with ScvO(2 )values ≤ 65% also showed higher 28-days mortality rate (31.3% vs 13.5%, P = 0.034), ICU LOS (28.5 ± 15.2 vs 16.6 ± 13.8, P < 0.001), and total hospital LOS (45.1 ± 20.8 vs 33.2 ± 24, P = 0.046) than patients with ScvO(2 )> 65%. CONCLUSION: ScvO(2 )value less than 65%, measured in the first 24 hours after admission in patients with major trauma and head injury, was associated with higher mortality and prolonged hospitalization

Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prospective observational study

Abstract Background Continuous monitoring of central venous oxygen saturation (ScvO2) has been proposed as a prognostic indicator in several pathological conditions, including cardiac diseases, sepsis, trauma. To our knowledge, no studies have evaluated ScvO2 in polytraumatized patients with brain injury so far. Thus, the aim of the present study was to assess the prognostic role of ScvO2 monitoring during first 24 hours after trauma in this patients' population. Methods This prospective, non-controlled study, carried out between April 2006 and March 2008, was performed in a higher level Trauma Center in Florence (Italy). In the study period, 121 patients affected by major brain injury after major trauma were recruited. Inclusion criteria were: 1. Glasgow Coma Scale (GCS) score ≤ 13; 2. an Injury Severity Score (ISS) ≥ 15. Exclusion criteria included: 1. pregnancy; 2. age 2 monitoring within 2 hours from the trauma. Demographic and clinical data were collected, including Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Simplified Acute Physiologic Score II (SAPS II), Marshall score. The worst values of lactate and ScvO2 within the first 24 hours from trauma, ICU length of stay (LOS), and 28-day mortality were recorded. Results Patients who deceased within 28 days showed higher age (53 ± 16.6 vs 43.8 ± 19.6, P = 0.043), ISS core (39.3 ± 14 vs 30.3 ± 10.1, P 2 resulted significantly lower (66.7% ± 11.9 vs 70.1% ± 8.9 vs, respectively; P = 0.046). Patients with ScvO2 values ≤ 65% also showed higher 28-days mortality rate (31.3% vs 13.5%, P = 0.034), ICU LOS (28.5 ± 15.2 vs 16.6 ± 13.8, P 2 > 65%. Conclusion ScvO2 value less than 65%, measured in the first 24 hours after admission in patients with major trauma and head injury, was associated with higher mortality and prolonged hospitalization.</p

Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu(H1N1)-related ARDS

<p>Abstract</p> <p>Background</p> <p>To describe the organization of an ECMO-centre from triage by telephone to the phase of inter-hospital transportation with ECMO of patients affected by H1N1-induced ARDS, describing techniques and equipment used.</p> <p>Methods</p> <p>From September 2009 to January 2010, 18 patients with H1N1-induced ARDS were referred to our ECMO-centre from other hospitals. Six patients had contraindications to treatment with ECMO and remained in the local hospital. Twelve patients were transported to our centre and were included in this study. Four patients were transported on ECMO (Group A) and eight on conventional ventilation (Group B). The groups were compared on the basis of adverse events during transport, clinical characteristics and outcome.</p> <p>Results</p> <p>The PaO2/FiO2 ratio was lower in the patients of Group A (46.8 vs 89.7 [median]) despite the PEEP values being higher (15.0 vs 8.5 [median]). The Murray score was higher in Group A (3.50 vs 2.75 [median]). During the transfer there were no significant complications noted in Group A, whereas two patients in Group B were reported with hypoxia (SpO2 < 90%). One patient in Group A died. All the other patients of the two groups have been discharged from hospital.</p> <p>Conclusions</p> <p>The creation of an ECMO team, with various experts in the treatment of ARDS, assured a safe transfer of patients with severe hypoxia, over long distances, when in other cases they wouldn't have been be transportable.</p

Diagnosis of carotid arterial injury in major trauma using a modification of Memphis criteria

<p>Abstract</p> <p>Background</p> <p>Incidence of Blunt Cerebrovascular Injuries (BCVI) after head injury has been reported as 0.5-1% of all admissions for blunt trauma, with a high stroke and mortality rate. The purpose of this study is to evaluate if a modification of Memphis criteria could improve the rate of BCVI diagnosis.</p> <p>Methods</p> <p>Trauma patients consecutively admitted to Intensive Care Unit (ICU) from Jan 2008 to Oct 2009 were considered for the study. Memphis criteria comprehend: basilar skull fracture with involvement of the carotid canal, cervical spine fracture, neurological exam not explained by brain imaging, Horner's syndrome, LeFort II-III fractures, and neck soft tissue injury. As single criteria modification, we included all patients with petrous bone fracture, even without carotid canal involvement. In all patients at risk of BCVI, 64-slice angio-CT-scans was performed.</p> <p>Results</p> <p>During the study period, 266 patients were admitted to the ICU for blunt major trauma. Among them, 162 presented traumatic brain injury or cervical spine fracture. In accordance with the proposed modified-Memphis criteria, 53 patients showed risk factors for BCVI compared to 45 using the original Memphis criteria. Among the 53 patients, 6 resulted as having carotid lesions (2.2% of all blunt major traumas; one patient more than when using Memphis criteria). Anticoagulant therapy with low molecular weight heparin was administered in all patients. No stroke or hemorrhagic complications occurred. Clinical examination at 6-months showed no central neurological deficit.</p> <p>Conclusion</p> <p>A modification of a single criteria of Memphis screening protocol might permit the identification of a higher percentage of BCVI. Limited by sample size, this study needs to be validated.</p