Penetrating injuries involving the intrathoracic great vessels

Approximately 50% of the forearm vasodilatation to intra-arterial infusions of acetylcholine is mediated by endothelium-derived nitric oxide. These conclusions have been derived from venous occlusion plethysmographic measurements of total forearm blood flow during co-infusions of acetylcholine and NG-monomethyl-L-arginine (L-NMMA), an inhibitor of nitric oxide synthase. Since venous occlusion plethysmography measures total limb blood flow, the relative proportion of the measurement from skin cannot be determined precisely. To determine the effects of acetylcholine on skin specifically, we have used laser Doppler flowmetry to measure vascular responses to local iontophoresis of acetylcholine in the forearm of normal male volunteers. To elucidate the possible mechanisms of cutaneous vasodilatation to acetylcholine, vascular responses were measured before and after systemic inhibition of prostanoid production and nitric oxide synthesis by oral aspirin (600 mg daily for 3 days) and intravenous L-NMMA (3 mg/kg for 60 min), respectively. After aspirin administration, dose-dependent vascular responses to acetylcholine were reduced significantly by approximately 53% (p < 0.005, ANOVA). In contrast, intravenous L-NMMA appeared to have no significant effect on cutaneous vascular responses to acetylcholine. While the role of nitric oxide is uncertain, vasodilatation to acetylcholine in the forearm skin is mediated largely by a prostanoid-dependent mechanism. Assessment of cutaneous vascular responses to iontophoresis of acetylcholine may, therefore, be useful in diseases where abnormal endothelium-dependent prostanoid function has been implicated.     

Penetrating ureteral injuries: the impact of associated injuries on management

The ideal management for penetrating ureteral trauma is primary repair, but the effect of other abdominal injuries might preclude this. We attempted to determine what factors could be used to predict a poor outcome of a ureteral anastomosis, so that the initial management can be modified appropriately. The case notes of 41 patients treated for penetrating ureteral trauma were studied retrospectively. Any factors that could influence postoperative complications and outcome were statistically analyzed in order to determine which could be used pre- or intraoperatively to indicate a poor prognosis for the ureteral anastomosis. The presence of shock on admission (P = 0.013), intraoperative bleeding (P = 0.006), colonic injury and specifically injury requiring colectomy (P = 0.006) were associated with a high complication and mortality rate. Patients presenting with penetrating ureteral trauma who are severely shocked and have complicated intraoperative hemostasis and patients who require colectomy should not have a primary ureteral anastomosis, but rather initial ureteral exteriorization or even nephrectomy.     

Spine and spinal cord war injuries during the war in Croatia

OBJECTIVE: The present report summarizes the experience of an evacuation hospital in southern Croatia in treating 96 patients with spine and spinal cord war injuries. METHODS: A retrospective review was done for 96 wounded persons (86 soldiers, 10 civilians) with spinal cord injuries from August 1991 through December 1995. The ages ranged from 15 to 59 years (mean, 28.3 years for soldiers, 38.5 years for civilians). Diagnostic procedures were plain radiography, computed tomography, and computed tomographic myelography. However, in most cases a more conservative surgical approach was used. RESULTS: The highest rates of admittance were recorded in 1992 (N = 38) and 1993 (N = 47). The lumbar spine was injured in 55% of the patients, the cervical and thoracic spines in 17.7%. All injuries were caused by projectiles from automatic rifles and sniper fire (51%) and from fragments of explosive devices (49%). Blast injury of the spinal cord was found in 10 patients. The most frequent complications caused by the fragments were wound infection, urinary tract infection, decubitus, and pneumonia. Four patients (4.2%) died in the hospital, and 43.0% of patients survived but were severely handicapped. CONCLUSION: Careful clinical examination combined with modern diagnostic imaging and use of broad-spectrum antibiotics reduced the need for surgical intervention in patients with spinal cord injuries.     

Abdomino-pelvic-gluteal war injuries. Principles of treatment

From a series of 316 cases of war wounds, the authors selected those cases in which the entry or exit wound was situated between the iliac crests and the inferior gluteal fold and report a series of 21 wounds (including 17 assault gunshot wounds) involving the perineal, pelvic and/or gluteal regions. Wounds of these regions are characterized by their immediate severity (10% mortality in this series), due to the complexity of combined lesions (urethra, rectum, hip, abdominal and vascular lesions) and the severity of sequelae. This series included 5 anorectal wounds, 5 urethral wounds and 4 hip wounds. Based on this series and a review of the literature, the authors discuss diagnostic problems (risk of missing abdominal penetration, a retroperitoneal rectal wound or an articular wound). Principles of treatments are also described (wide debridement and drainage, systematic colostomy for wounds of the rectum and large soft tissues wounds, systematic cystostomy for bladder and urethral wounds and alignment of urethral wounds whenever possible, articular lavage and immobilization by external fixation of hip wounds).     

Penetrating eye injuries associated with motor vehicle accidents

A 2 1/2-year review of penetrating eye injuries resulting from motor vehicle accidents and treated at the Princess Alexandra Hospital, Brisbane, is presented. The series dates from January 1, 1972, when legislation requiring the compulsory wearing of seat belts was introduced. The review shows a downward trend in injuries compared with the previous 6 1/2 years. Almost all the patients failed to wear a lap-and-sash seat belt or, if one was worn, it was not secured properly.     

Penetrating ocular injuries: an epidemiologic and retrospective study

Penetrating injuries of the eye are an important cause of unilateral visual loss. We studied a series of 82 cases of penetrating injuries treated here from 1987 through 1993. The injuries were caused by sharp objects in 66% and blunt trauma in 6%. The prognosis after a penetrating injury is greatly influenced by the nature of the injury and the extent of the initial drainage. Among factors associated with an unfavorable visual outcome were diminished preoperative visual acuity and scleral wounds with dense vitreous hemorrhage.     

Unexplained deaths in war injuries in Bosnia and Herzegovina

The paper presents the research in cases of the unexpected and sudden of the patients injured by fire-arms, during the aggression on BH. On the basis of the results of the origin of injury, the period of providing medical aid, the level of tissue damage and the function disturbancy, it could be concluded that numerous factors which are typical for the state of war are included comarde to the influencing factor of injuries observed in the incidents in the times of peace. The injuries in the course of the aggression are characterized by a severe tissue damage which is frequently followed by the poison gases poisoning, the quality of the first aid given, delayed and aggravated transportation, multi-organic disbalance of the morphological structures and functions as well as an increased development of these mediators which bring about this type of disbalance. The lack of chemical diagnostic means prevents the determination of existence of the indicators of threatening deaths in the cases where there are no clinical signs for a fatal outcome. The frequency of casualties has prevented the prompt control of the biochemics and thus resulted in the increase of the number of unexpected and unclarified deaths.     

Penetrating chest injuries in children: a review of 94 cases

Ninety-four children with penetrating chest injuries were treated at Dicle University School of Medicine during a 6-year period. The mean age was 11.51 +/- 3.31 years, and the male:female ratio was 5.25:1. Forty-five had stab wounds, 27 had high-velocity gunshot wounds, 13 had low-velocity gunshot wounds, seven had a bomb (shrapnel) injury, one had a shotgun wound, and one had a horse bite. Sixty patients had isolated thoracic injuries, and 34 had associated injuries. The most common thoracic injury was hemothorax (28), followed by hemopneumothorax (25). Tube thoracostomy alone was sufficient in 79.8% of the patients (75 of 94). Thoracotomy was performed in 4.25% (4 of 94). In two of the five observed patients, delayed hemothorax developed. The mean duration of hospitalization was 5.13 +/- 1.93 days. The mean Injury Severity Score was 14.71 +/- 8.62. Prophylactic antibiotics were used in all patients. The morbidity rate was 8.51% (8 of 94). Only one death occurred after cervical tracheal repair. The study suggests that the majority of penetrating chest injuries in children can be treated successfully by tube thoracostomy alone or in conjunction with expectant observation.     

Penetrating injuries of the orbital roof caused by the point of an umbrella

Two lethal cases of penetration injury of the orbita are reported. The injuries were caused directly by the point of an umbrella (accident or homicide), leading to canalicular destruction of the frontal lobe of the cerebrum. The mechanism of injury with cerebral involvement was not determinable except by autopsy, and the importance of a thorough clinical examination is therefore emphasized.     

A pseudoaneurysm after repair of thoraco-abdominal aortic aneurysm

We report a 63-year-old female patient developing a pseudoaneurysm three years after patch-plasty of an aneurysm located at the distal thoracic aorta. Redo-operation was performed including total replacement of the descending thoracic aorta with reimplantation of distal intercostal arteries using small-caliber interposition grafts. This case presentation underlines the ineffectiveness of patch repair for the treatment of aortic aneurysms. Furthermore, the surgical technique of reimplantation of intercostal arteries using a separate graft is discussed.     

Diagnosis and treatment of penetrating thoraco-abdominal peace-time wounds

A formula describing weight losses in the first approximation during space mission was derived assuming that humans may adapt to space flight effects. The process depended on two parameters one of which characterized maximum body losses and another--time of adaptation. Weight estimates of Skylab crewmembers obtained with the aid of the formula were in good agreement with actual results. The typical time of adaptation was two days. Possible ways of constructing a more precise model of weight changes and its use to diagnose the status of crewmembers are discussed.     

Penetrating missile embolisation

The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exist. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X-ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficial femoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years.     

Penetrating chest trauma

This article reviews the current concepts in penetrating chest trauma. The authors discuss mechanisms of injury, nursing assessment, and interventions for penetrating injuries resulting in cardiac rupture, cardiac tamponade, tension pneumothorax, hemothorax, great vessel injury, and sucking chest wounds.     

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.     

Penetrating neck trauma

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.