Management of traumatic diaphragmatic injuries

Introduction. Diagnostic and curative management of diaphragmatic lesions (DLs) is still difficult, representing a significant medical problem in both penetrating and blunt trauma. Aim of study. To review the anatomy and physiology of the diaphragm, to describe the clinical presentation of traumatic DLs, and to discuss the diagnosis and therapeutic options available for traumatic DLs while highlighting the role of the trauma team in evaluating patients with this condition Methods and materials. Retrospective study was conducted between 2014−2021 in Surgery Department Nr.1 ”Nicolae Anestiadi”, the Institute of Emergency Medicine, which included 48 patients with diaphragmatic lesions. The following parameters were evaluated: epidemiological data, trauma causes, defect size, presence of associated lesions, mean time from injury to surgery, applied surgical procedure, and postoperative morbidity and mortality. Results. M:W ratio 2:1, mean age–35±13.4 years. Penetrating injuries were registered in 38 (79.2%) cases, while blunt abdominal trauma in 10 (20.8%) situations. Traumatic events: stabbing–35 (72.9%), aggression–2 (4.2%), car crashes–9 (18.75%), and catatrauma–2 (4.2%). On admission 13 (27.1%) patients were hemodynamic unstable. The following diagnostic tests were performed: chest radiography−39 (81.25%), FAST−36 (75%), Computed Tomography−15 (31.25%), laparoscopy−15 (31.25%), and thoracoscopy−3 (6.25%). In most cases, the diagnosis was established during first 72h after traumatic event−43 (89,6%). DL was discovered preoperative in 23 (48%) cases, while intraoperative in 25 (52,1%) victims. Isolated DL was established in 8 (16.7%) cases, accompanied injuries were present in another 40 (83.3%) situations, including parenchymatous organ injury−23 (57.5%), hollow organ lesion–12 (30%), and lung damage−7 (14.6%). DL was localized on the left side in 33 (68.75%) cases, on the right side−15 (31.25%), the wound diameter ranging from 0.5cm to 20cm. Surgical treatment was applied in all the cases. The following surgical access techniques were used: laparotomy−40 (83.3%), thoracotomy−2 (4.2%), combined thoracoabdominal access−3 (6.3%), and thoracoscopy−3 (6.3%). The surgical procedure involved a reduction of herniated viscera, treatment of associated lesions, and defect repair by simple suture in 46 (95.8%) cases, and duplication−2 (4.2%). Postoperative mortality−2 (4.2%). Conclusion. Diaphragmatic injury should be routinely suspected in patients with chest or abdominal trauma. The most common diaphragmatic lesion is found intraoperatively, the laparotomy being dictated by the hemoperitoneum. In patients with inferior thoracic wounds and hemodynamic stability, laparoscopy and thoracoscopy can definitely establish the diagnosis. In addition, in the absence of intraabdominal lesions, thoracoscopy allows definitively to resolve the defect

MANAGEMENT OF SHOULDER DYSTOCIA

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaIntroducere. Distocia de umăr reprezintă o urgență obstetricală caracterizată prin naștere vaginală în prezentație craniană cu incapacitatea de degajare a umerilor fetali și necesitatea manevrelor obstetricale suplimentare pentru nașterea fătului după degajarea capului și eșuarea tracțiunii blânde a acestuia. Scopul lucrării. Revizuirea datelor existente privind factorii de risc, managementul, complicațiile distociei de umăr. Material și metode. Datele au fost colectate din literatura de specialitate (24 articole- PubMed), protocoale clinice naționale standardizate (7 - Republica Moldova, România, Marea Britanie, Danemarca, Franța, Suedia, Australia). Rezultate. Factorii de risc: prenatali – macrosomie, DZ, IMC mamei >30kg/m2; intrapartum – travaliu prelungit, naștere vaginal asistată. Se evită eforturile explulzive, tragerea capului fătului, rotirea capului prin răsucirea gâtului, aplicarea presiunii fundice, secționarea cordonului ombilical. Manevra de elecție – McRoberts. În cazul eșuării se realizează: manevra de răsucire Wood, Wood inversată, nașterea brațului posterior, manevra Gaskin, manevra Menticoglu. Abordările drastice: manevra Zavanelli, fractura intenționată a claviculei și simfiziotomia. Complicațiile distociei de umăr: fetali – leziunea nervilor plexului brahial (4-16%), fracturi claviculare/humerale (0,1-9,5%), asfixie fetală (0,3%), deces (0-0,35%); materne – hemoragie postpartum (11%), lacerații vaginale/cervicale/perianale, diastaza simfizei, ruptură uterină. Concluzii. Distocia de umăr este o urgență obstetricală imprevizibilă. Personalul medical trebuie instruit pentru situații de urgență care impun cunoașterea manevrelor indispensabile degajării umerilor fetali în distocia de umăr, deoarece aceasta reprezintă un risc crescut de morbiditate maternă și fetală și este considerată una din cauzele cele mai controversate în obstetrică.Background. Shoulder dystocia is an obstetric emergency characterized by vaginal delivery in cranial presentation with the inability to release the fetal shoulders and the need for additional obstetric maneuvers to deliver the fetus after head release and failure of its gentle traction. Objective of the study. Review of existing data on risk factors, management, complications of shoulder dystocia. Material and methods. Data were collected from specialized literature (24 articles - PubMed), standardized national clinical protocols (7 - Republic of Moldova, Romania, Great Britain, Denmark, France, Sweden, Australia).Results. Risk factors: prenatal – macrosomia, DM, mother’s BMI >30kg/m2; intrapartum – prolonged labor, assisted vaginal birth. Explosive efforts, pulling the fetal head, turning the head by twisting the neck, applying fundal pressure, cutting the umbilical cord are avoided. Election Maneuver – McRoberts. In case of failure, the following are performed: Wood twisting maneuver, inverted Wood, rear arm delivery, Gaskin maneuver, Menticoglu maneuver. Drastic approaches: Zavanelli maneuver, intentional clavicle fracture, and symphysiotomy. Complications of shoulder dystocia: fetal – brachial plexus nerve injury (4-16%), clavicle/humeral fractures (0.1-9.5%), fetal asphyxia (0.3%), death (0-0.35%); maternal – postpartum hemorrhage (11%), vaginal/cervical/perianal lacerations, symphysis diastasis, uterine rupture. Conclusion. Shoulder dystocia is an unpredictable obstetric emergency. Medical staff must be trained for emergency situations that require knowledge of the maneuvers necessary to free the fetal shoulders in shoulder dystocia, as this represents an increased risk of maternal and fetal morbidity and is considered one of the most controversial causes in obstetrics