Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines

Splenic trauma : WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.Peer reviewe

Axillary calcifying fibrous tumor (CFT) in an 8 year old girl

Calcifying fibrous tumors (CFTs) are benign soft tissue masses that can occur at many sites. This case report outlines the diagnostic workup for this rare, fast-growing, solitary mass in an otherwise healthy 8 year old patient. We also describe the radiographic and pathological characteristics unique to this lesion

Tracheal resection and reanastomosis in the neonatal period

Background/purpose: Severe congenital tracheal stenosis is rare. Most of these can be managed conservatively before elective repair. Focal tracheal stenosis has been treated with resection of the involved trachea and primary reanastomosis in older infants. The authors found no reports of repair of this lesion in neonates. Two patients are presented with severe respiratory failure on the first day of life that required extracorporeal life support (ECLS) who underwent successful tracheal resection and reanastomosis (TRR) during the first week of life.Methods: A retrospective review was conducted.Results: Both babies had severe pulmonary hypertension and carbon dioxide retention despite maximal therapy and were placed on ECLS shortly after transfer. One had an isolated stenosis of the upper trachea, and the other had agenesis of the right lung, esophageal atresia with tracheoesophageal fistula, and a tracheal stenosis at the end of a short trachea with a long, narrow left bronchus. Both underwent diagnostic studies and had surgical repair while on ECLS at day 3 and 7 of life without bleeding complications. They were weaned off ECLS 1 and 8 days after surgery. One patient was extubated and did well. The other was extubated transiently, but required a tracheostomy because of left mainstem bronchomalacia. Both are alive and well at 18 and 38 months of age, with no narrowing of the repairs.Conclusion: In the setting of severe respiratory failure requiring ECLS support, TRR can be performed safely and successfully in the neonate with focal tracheal stenosis

Extracorporeal membrane oxygenation for nonneonatal acute respiratory failure

Hypothesis: Extracorporeal membrane oxygenation (ECMO) is effective in nonneonatal acute respiratory failure under certain circumstances.Design: Retrospective medical record review.Setting: The intensive care unit of a tertiary care hospital.Patients: Thirty-four nonneonatal patients (mean age, 22 years; range, 8 days to 56 years), with ratios of the PaO2 to the fraction of inspired oxygen persistently below 70, who were treated with ECMO after maximal ventilator therapy had failed (mean time of ventilator therapy, 6.9 days; range, 1-41 days). The mean ECMO duration was 304 hours (range, 56-934 hours). Patients were grouped into 7 categories based on their diagnosis: sepsis or sepsis syndrome (n = 3), bacterial or fungal pneumonia (n = 10), viral pneumonia (n = 5), trauma or burn (n = 2), inhalation injury without burn (n = 1), immunocompromised state (due to transplantation or chemotherapy) (n = 8), and acute respiratory failure of unknown origin (n = 5).Main outcome measure: Survival to hospital discharge following ECMO therapy.Results: Overall survival was 53% (18 patients). All 6 patients (100%) with viral pneumonias or isolated inhalation injuries survived. Of 13 patients with bacterial pneumonia, sepsis, or sepsis syndrome not complicated by multiorgan failure, 10 (77%) survived. In contrast, all but 1 of the immunocompromised patients died. Survival in patients who were intubated for less than 9 days before ECMO was 64%, whereas survival fell precipitously to 22% for patients who experienced mechanical ventilation for 9 or more days before the implementation of ECMO. Finally, the proportion of patients who died while receiving ECMO therapy was greater when the ECMO duration exceeded 300 hours (62% vs. 38%; P\u3c.05).Conclusions: Nonneonatal survival with ECMO therapy is strongly dependent on the diagnosis. Pre-ECMO intubation for less than 9 days had little effect on survival. Survival rates decreased when the length of time of receiving ECMO exceeded 300 hours

Primary pulmonary rhabdomyosarcoma in a 5-month-old boy: a case report

Primary pulmonary rhabdomyosarcoma (RMS) in the pediatric population is a rare entity. A 5-month-old boy initially treated for pneumonia was proven to have a primary pulmonary RMS, which was resected via thoracotomy. After a course of chemotherapy following the Children's Oncology Group low-risk RMS protocol (ARST0331), a restaging chest computerized tomography scan showed local recurrence, which was also resected by open thoracotomy. The patient is currently undergoing local radiotherapy and salvage chemotherapy regimen. This patient is the youngest reported to date with this entity. The prognostic significance of his young age and the morphologic findings of his tumor are unclear

Substance use patterns and in-hospital care of adolescents and young adults attending music concerts

Background: Few studies describe medical complaints and substance use patterns related to attending music concerts. As such, the objective of this study is to describe patient demographics, substance use and intoxication patterns, and medical interventions provided to adolescents and young adults assessed in an emergency department (ED) for complaints directly related to concert attendance. Methods: A retrospective chart review of patients 13–30 years old who were transported to the ED directly from music concerts between January 2011 and December 2015 was conducted. Descriptive statistics and logistic regression were used to analyze patient demographic, intervention, and substance use data. Results: There were 115 concerts identified, of which 48 (42%) were linked to 142 relevant ED visits; the total number of attendees at each concert is unknown. The mean age of the 142 described patients was 19.5 years (SD 3.3) with 72% < 21 and 33% < 18; 71% of patients were female and 96% of visits were substance-use related. Mean blood alcohol level was 242 mg/dL (range 104–412, SD 70). Glasgow Coma Scale (GCS) scores ranged from 3 to 15, with a mean of 14. Two patients required intubation and 61% of patients received interventions, including medications (47%), intravenous fluids (46%), specialty consultation (20%), restraints (14%), imaging (6%), and laceration repair (3%). Attendance at pop and electronic dance music concerts was associated with the widest ranges of GCS scores (8–15 and 6–14 respectively), mass casualty incident declarations, and among the highest mean blood alcohol levels (246 and 244 mg/dL, respectively). Conclusions: Substance use is the predominant reason for music concert related ED visits and patients may have serious levels of intoxication, receiving multiple medical interventions. These data demonstrate the need for additional large-scale studies to confirm trends and increase awareness of this important public health problem