Head trauma

Progress in research includes studies concerning the pathophysiology and outcome of pediatric head injury, the pathology of the hippocampus in fatal injury, and the use of multivariate statistics to predict outcome in survivors. Recent research has confirmed and extended findings regarding the differential effects of closed head injury, depending on the age of the individual. These studies indicate that the consequences of head injury are more severe in older adults and in children younger than 2 years. Neuroimaging findings include evidence for delayed brain injury as a major cause of mortality and disability. Functional brain imaging provides evidence for cerebral dysfunction that is not appreciated by structural brain imaging techniques and may have a stronger relationship to neurobehavioral sequelae. The neurobehavioral sequelae frequently implicate frontal dysfunction, even in the absence of structural findings on computed tomography or magnetic resonance imaging. Studies of mild head injury have expanded our knowledge concerning the pathogenesis of postconcussional symptoms, including a preinjury vulnerability based on recent life events. Persistent postconcussional symptoms after mild head injury are frequently associated with emotional disturbance of clinical proportions.     

Orbital trauma

To study factors influencing the distribution of local anaesthetics in the subarachnoid space, an in vitro model is constructed which takes into account the natural curvature of the spinal column and the volume occupation of spinal cord and nerve fibres to resemble the in vivo situation. Three Marcaine solutions of different baricity (1003, 1008, 1030 kg/m3) are injected with a 22 G, a 27 G Quincke point needle and a 18 G multiport catheter into three models of non-pathological spinal columns with injection flow speeds of 0.6, 0.2 or 0.1 ml/s. Methylene blue is added for visual and qualitative assessment of drug distribution. Baricity is the main actor in the spreading of the drug solution. For all other variables, no significant difference is found after ten minutes, though the initial distribution may differ according to the geometry used. A hypobaric solution yields a remarked difference between fast and slower injections. The position of the catheter should be controlled.     

Thoracic trauma

Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early management of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. Most of the isolated thoracic injuries are adequately treated by conservative means, sufficient analgesia, drainage of intrapleural air or blood, physiotherapy and clearance of bronchial secretions provided; operative intervention is rarely indicated. In multiple injured patients however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase of morbidity and mortality. Hence, patients with this combination of pulmonary injuries, such as lung contusion and associated severe injuries, carry a particular high risk of respiratory failure, ARDS and MOF with a considerable mortality. Therefore, early exact diagnosis of all thoracic injuries is essential and can be achieved by thoracic computed tomography, which becomes more and more popular in this setting. Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.     

Multiorgan trauma

A case is presented of a patient with multiorgan trauma. The main diagnostic problem was coexisting haemorrhage. Curable skin defects were healed after several covering them with intermediate thickness mesh grafts. The postoperative course was complicated with sepsis and acute non-inflammatory renal failure with polyuria.     

Spinal trauma

In the workup of patients suffering from spinal trauma the radiologist is eager to make a proper diagnosis asking only for few additional examinations. This can be done by a functional and biomechanical approach in reading standard radiographs. With the knowledge of the kind of injury expected the whole extent of posttraumatic changes in the spine can be delineated exactly. The goal is to make a diagnosis that answers questions of stability so the traumatologist can be aided in therapy.     

Geriatric trauma

This article reviews the salient aspects of geriatric trauma, including common injury mechanisms, physiologic differences in elderly patients, and their prehospital and emergency department evaluation. Specific organ injuries and associated mortality are also discussed.     

Pediatric trauma

Trauma is the leading cause of death in infants and children. Caring for the pediatric trauma victim requires a systematic approach which utilizes an understanding of the anatomic and pathophysiologic characteristics that make children different from adults. Child abuse frequently presents as trauma, making a high index of suspicion for mechanism and severity of injury an important component of trauma assessment. A basic approach to managing pediatric trauma with emphasis on initial stabilization is presented, followed by discussion of specific areas including head and neck trauma, chest trauma, abdominal trauma, and extremity trauma.     

Congenital esophageal stenosis presenting as noncardiac, esophageal chest pain

A case of a 31-year-old female with congenital esophageal stenosis presenting with symptoms of chest pain caused by esophageal dysmotility is described. The involved segment in congenital esophageal stenosis has a characteristic thickening of the muscularis propria layer, as seen by EUS examination. In these patients, symptoms of dysphagia can be managed with esophageal dilation and noncardiac esophageal chest pain responds to pharmacotherapy with diltiazem.     

Vertebral artery trauma

The developmental consequences of paternal exposure to acrylamide (50 mg/kg i.p. for 5 days) were assessed in preimplantation embryos. There was a significant increase in the proportion of morphologically abnormal embryos after postmeiotic treatment during spermatogenesis (88.7% vs. 14.8% in control). Abnormal embryos had an average of 1.8 +/- 3.5 cells and > 80% had at least one fragmented nucleus. In addition, morphologically normal embryos were significantly delayed (34.3 +/- 12.8 cells per embryo vs. 57.6 +/- 15.7 in control, P < 0.001). Acrylamide caused 10- and 20-fold increases in frequencies of cells with micronuclei (MN) in morphologically normal and abnormal embryos, respectively (41 and 93 MN per 1,000 cells). Both centromere-negative (MN-) and centromere-positive (MN+) were induced. Nuclei of abnormal embryos were significantly larger (900 microm2 vs. 250 microm2) than controls. In addition, MN of abnormal embryos were larger than those of normal embryos (21.2 microm2 vs. 6.5 microm2, P < 0.01). Among control embryos, MN+ were significantly larger than MN- (P < 0.05). These findings suggest that the preimplantation embryo is a sensitive indicator of paternally transmitted effects on early development. Multiple mechanisms appear to be involved, including cytogenetic damage, proliferation arrest/delay, and fertilization failure. Future studies are needed to establish how induced cytological defects in preimplantation embryos contribute to birth defects and other postimplantation abnormalities.     

Penetrating thoracoabdominal trauma

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.     

Primary esophageal melanoma

Three cases of cartilaginous choristomas of the tongue are presented. Two lesions occurred in women of 71 and 28 years of age whose lesions were located in the middle third of the dorsum. The other lesion was found on the left lateral border in a 27-year-old man. The clinical, microscopic and immunohistochemical features are described. The lesions were easily excised with no recurrence after follow-up periods of at least 6 months. The histogenesis and the differential diagnosis are discussed, and the literature is reviewed.     

Mild head trauma

Patients with mild traumatic brain injury constitute the overwhelming majority of head-injured patients seen in the emergency department. The indications for radiologic imaging in these patients are still undergoing study and revision. The Glasgow Coma Scale is a widely used triage score for head injury, but is less useful at identifying which patients with mild head injuries have intracranial pathology. There have been several retrospective studies and a few prospective studies examining the indications for imaging in mild to moderate head trauma. They all show that it is not easy to predict which patients will have CT abnormalities, and that some of these patients do go on to require neurosurgery. No set of clinical predictors have yet been put together that is capable of identifying all patients who are safe to be discharged without a CT scan. Pharmacologic therapy to help reduce axonal damage after head trauma and thus minimize the postconcussive sequelae of mild traumatic brain injury remains a challenge for physicians and neurobiologists into the next century.     

Pediatric elbow trauma

Acute pediatric elbow trauma is commonly seen in the emergency department (ED). Reports confirm that, compared to other fractures, children's elbow fractures are commonly misdiagnosed in the ED. In addition, missed orthopedic injuries are one of the leading causes of malpractice claims in emergency medicine. Radiologic diagnosis of these injuries is challenging, as a large portion of the pediatric elbow is composed of radiolucent cartilage. Knowledge of the normal anatomy and ossification centers around the elbow is essential for correct diagnosis. Acute neurovascular injury is frequently associated with these injuries, but is often difficult to assess in an apprehensive child. Immediate orthopedic consultation is indicated for any child with an elbow injury in whom neurologic or vascular compromise is suspected. Consultation should be strongly considered for children with displaced supracondylar fractures and/or significant echymosis and swelling about the cubital fossa.     

Blunt abdominal trauma

Assessment and management of patients with blunt abdominal trauma remains a challenge for emergency physicians. The spectrum of injury ranges from the trivial to the catastrophic and the initial assessment, resuscitation, and investigation of patients with abdominal trauma must be individualized. This article covers the important aspects of patient history and physical examination and addresses the relevant investigative tools available. An approach to the assessment of patients with abdominal trauma is provided; the goal is to diagnose significant injuries as soon as possible and avoid the pitfall of a delayed or missed diagnosis.     

Minor head trauma

This article reviews the persisting difficulty and the importance of the diagnosis of minor head trauma. The diagnosis has been complicated by pervasive disagreement regarding diagnostic criteria. This is primarily a result of the fact that evidence for actual injury is hard to obtain in minor cases because most symptoms tend to be subjective and have high base rates in the normal, uninjured population. At the same time, the diagnostic decision has important implications for patients in terms of treatment, expectancy for future function and lifestyle, and compensation for injuries. Decision theory leads us to the awareness of diagnostic errors. In addition to correct determination, the clinician can make an error of not diagnosing an injury when it has in fact occurred or making a positive diagnosis where there is no injury. The optimal strategy is to set the cutoff at the midpoint of these two error probabilities. The clinician may be willing to make one error rather than the other depending on the cost and bias involved. The second error is more likely to be made when the clinician stands as a strong advocate for the patient and willing to provide any help necessary to encourage treatment, give patients a rationale for understanding their symptoms, and help them obtain compensation for injuries. This can also lead to significant overdiagnosis of injury. The first error is more likely to be made when the clinician recognizes the potential for increasing costs to the health-care industry, the court system, and increasing personal injury claims. He or she may also recognize the vulnerability to the risk for symptom invalidity, the perpetuation of patient symptoms through suggestion, and the need for a biologic explanation for life stressors and preexisting emotional and personality constraints. It can be argued that the most objective diagnostic opinion, uninfluenced by the above biases, should ultimately be in the best interest of the patient, the clinician, legal consultants, and society. Based on the findings in this chapter, at least four symptom constellations can be identified. These have differing probabilities for residual symptoms of minor head trauma and include the following: 1. These patients' symptoms clearly meet the criteria from Table 2. This includes several findings from 1 to 10 of Table 1, together with abnormal neuropsychologic testing on the AIR, General Neuropsychological Deficit Scale, or other indicators of diminished cortical integrity. This group of patients shows a very strong probability of having experienced a brain injury and for showing residual symptoms of minor head trauma. 2. These patients have experienced concussional symptoms (e.g., headache, mild confusion, and balance and visual symptoms) that were documented at the time of injury but sustained no or brief (< 15 seconds) LOC or PTA and, therefore, do not qualify for the diagnosis in Table 2. They may still have several symptoms from Table 1, including objective findings from neuroscanning and variable neuropsychologic testing, especially in measures of attention and delayed recall. This group also shows a high probability for residual, unresolved concussional, and related symptoms. 3. These patients may have shown evidence of concussional symptoms at the time of injury, with no or brief LOC, PTA, or other symptoms from Table 1 (1-10). They continue to show persistent symptoms after 6 months to 1 year. With this group, there is a strong probability that emotional, motivational and premorbid personality factors are either causing or supporting these residual symptoms. 4. In these patients, clearly identifiable postconcussive symptoms at the time of injury are not easy to identify, and perhaps headache is the only reported symptom. There was no LOC or PTA, and virtually none of symptoms 1 to 10 in Table 1 are observed. These patients show strong evidence of symptom invalidity on MMPI-2 or other measures, and marked somatoform, depression, anx