Search

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity., Methods: This was a retrospective chart review of patients presenting to a single level 1 trauma center from January 2013-June 2016. Patients with penetrating trauma to the extremity and no hard signs of vascular injury were included. Physical examination and computed tomography angiography findings were analyzed, with particular focus given to missed injuries., Results: We identified 393 patients with penetrating trauma to the extremity without hard signs of vascular injury. Computed tomography angiography was performed in 114 patients (29%). Four patients with distal pulses documented on their initial trauma surveys were found to have vascular injuries on computed tomography angiography, although 3 of these injuries were identified on repeat physical examination. One additional patient had a delayed presentation of a pseudoaneurysm. No mortality or limb loss resulted from these injuries. Total hospital charges for computed tomography angiography amounted to over $700,000., Conclusion: Patients with penetrating trauma to the extremity and no hard signs of vascular injury do not require computed tomography angiography for identification of clinically relevant vascular injuries that require emergent operative repair. Serial physical examination appears to provide accurate detection of vascular injury requiring procedural intervention., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Lightning strike victims are rarely presented at an emergency department. Burns are often the primary focus. This case report describes the improvised explosive device like-injury to the thorax due to lightning strike and its treatment, which has not been described prior in (kerauno)medicine. Penetrating injury due to blast from lightning strike is extremely rare. These "shrapnel" injuries should however be ruled out in all patients struck by lightning., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: Prevertebral soft tissue measurements of more than 6 mm at C2 and more than 22 mm at C6 have been reported as radiologic evidence of cervical spine injury. The objective of this study was to determine the sensitivity and specificity of soft tissue measurements in patients with radiographically proven cervical spine fractures., Design: Retrospective case control study., Setting: Level I trauma center emergency department., Participants: The study group consisted of patients admitted between January 1989 and August 1991 with an admitting or discharge diagnosis of cervical spine fracture. The control group was a systematic sampling of trauma patients seen in the ED during July 1991 who received a cervical spine radiograph. Patients less than 17 years old with penetrating injuries or injuries more than 24 hours old were excluded. One hundred thirty-eight study patients and 134 control patients were identified; 32 study patients and 41 control patients were excluded due to inaccessible records. One hundred six study patients and 93 control patients were used for data analysis., Results: Study patients were divided into two groups: those with fractures at C1-C4 (n = 55) or C4-C7 (n = 86). A C2 prevertebral soft tissue measurement of more than 6 mm had a sensitivity of 59% and a specificity of 84% for fractures at C1-C4. A C6 prevertebral soft tissue measurement of more than 22 mm had a sensitivity of 5% and a specificity of 95% for fractures at C4-C7. Receiver operator characteristic curves for measurements at C2 and C6 failed to demonstrate a cutoff value with adequate sensitivity and specificity in detecting fracture., Conclusion: We conclude that using prevertebral soft tissue measurements of more than 6 mm at C2 and more than 22 mm at C6 as a marker of cervical spine injury fails to identify a large proportion of patients with cervical spine fractures.

Study Hypothesis: Femoral artery injuries can be predicted by the mechanism of injury, wound location and tract, and physical findings following penetrating thigh trauma., Design: Retrospective case-control study., Participants: All 808 consecutive patients undergoing femoral arteriography for penetrating thigh trauma from September 1986 through December 1990 were eligible for inclusion in the study. All 50 patients in the eligible population with proven femoral artery injuries diagnosed by angiogram were the study subjects. Fifty patients with penetrating thigh trauma who had angiograms negative for injury and were systematically chosen from the eligible population served as controls., Interventions: Data included mechanism of injury; location of wound entrance, tract, exit, and retained missile; physical findings (including ankle-brachial index); and the presence of femur fractures. Physical findings were divided into hard findings (pulse abnormality, expanding hematoma, or pulsatile bleeding) or soft findings (neurologic deficit, hypotension without another source, or bruit/thrill)., Results: Of the 808 eligible patients, 50 (6.2%) had a femoral arterial injury on angiography, 20 (40%) of which were clinically occult injuries. A medial thigh tract made an arterial injury 58 times more likely (odds ratio [OR], 57.5; P < .001) and was present in 100% of cases and 64% of controls. An anteromedial thigh tract made an arterial injury 12 times more likely (OR, 11.5; P < .001) and was present in 92% of cases and 50% of controls. A wound with hard physical findings was 118 times more likely to have an arterial injury (OR, 118; P < .00001) and was found in 54% of cases and none of the controls. The presence of any physical finding made an arterial injury 36 times more likely (OR, 36; P < .00001) and was found in 60% of cases and 4% of controls. The presence of a femur fracture or a gunshot mechanism was not predictive of injury., Conclusion: Only patients with medial thigh wounds need to undergo angiography for the detection of femoral artery injuries. This approach would have reduced the angiography rate by 36% in this series. Had angiography been performed only on patients with any physical findings, a 70% reduction in the rate of angiography would have been achieved, although five occult arterial injuries per year would have been missed. Angiography should not be performed solely because of a gunshot mechanism or the presence of a femur fracture.

A case of traumatic transection of the thyroid gland with secondary substantial hematoma and respiratory distress is presented. Hemorrhage into the altered thyroid gland is well known. However, there are only a few reports of severe hemorrhage associated with trauma. A short review of the literature is given and the mechanism of trauma is discussed.

Study Objective: To describe patient and wound characteristics that are clinically useful in identifying wounds that were caused by glass and retained a foreign body., Design: Retrospective consecutive case review., Setting: Urban, university-affiliated teaching hospital., Type of Participants: Four hundred thirty consecutive patients with a total of 578 evaluable wounds caused by glass during a 12-month period., Measurements and Results: Medical records were reviewed to determine patient demographics, primary wound data (eg, location, type, description), mechanism of injury, type of glass involved, and presence of foreign body sensation. Glass was found by examination in 7% of wounds. Eight percent of 137 radiographs were positive. Wounds with the highest prevalence of retained glass were puncture wounds (P < .0005), those caused by stepping on glass or by a motor vehicle accident (P < .005), and those of the head or foot (P < .003)., Conclusion: Characteristics of wounds most likely to retain glass were identified in this retrospective study. The presence of these factors should increase the clinician's suspicion of a retained glass foreign body. The indications for radiography for the detection of retained glass in wounds should be clarified with prospective studies.

Study Objectives: To determine the effect of immediate two-dimensional echocardiography on the time to diagnosis, survival rate, and neurologic outcome of patients with penetrating cardiac injury., Design: A ten-year retrospective review., Setting: Regional trauma center serving a population base of 1.25 million with 85,000 visits yearly., Type of Participants: All patients presenting to the emergency department with penetrating cardiac injury., Measurements and Main Results: The records of 49 patients with penetrating cardiac injury were reviewed. Of these, 28 received immediate two-dimensional echocardiography in the ED (echo group) and 21 did not (nonecho group). The probability of survival was derived using TRISS methodology. Differences between groups were determined using either the two sample t-test for parametric data or the Mann-Whitney test for nonparametric data. The overall probability of survival was 33.2%, and the actual survival rate was 81.6%. The probability of survival was 34.2% and 31.8% for the echo group and nonecho group, respectively. The actual survival was 100% in the echo group and 57.1% in the nonecho group. The average time to diagnosis and disposition for surgical intervention was 15.5 +/- 11.4 minutes for the echo group and 42.4 +/- 21.7 minutes for the nonecho group (P less than .001). The Glasgow Outcome Score was 5.0 for the echo group and 4.2 for the nonecho group (P = .007)., Conclusion: Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.

Fishhook injuries rarely pose a true emergency, and only a few cases of posterior ocular injury from fishhooks have been described. We present a case of penetrating ocular, orbital, and cranial trauma produced by a broken fishhook. The morbidity and mortality as well as the initial emergency evaluation of penetrating foreign objects in the orbital-cranial region are discussed.

Forty-seven patients with 50 clinically occult injuries of major arteries were studied prospectively to determine the natural history of these lesions and the safety of nonoperative management. Penetrating trauma was the predominant mechanism and lower extremity arteries were most commonly involved. The morphology of these arterial injuries included 22 cases of intimal flaps, 21 cases of segmental arterial narrowing, 6 pseudoaneurysms, and 1 acute arteriovenous fistula. There was one death as a result of unrelated causes and another three injuries operated on immediately after arteriographic diagnosis. The remaining 46 injuries were followed up nonoperatively by serial arteriography (39) or clinical examination (7) during a mean interval of 3.1 months (range, 3 days to 27 months). Complete resolution was documented for 29 injuries (63%), whereas 3 improved, 9 remained unchanged, and 5 worsened during the period of follow-up. All worsened cases involved small or occult pseudoaneurysms that subsequently enlarged and then underwent immediate surgical repair without subsequent morbidity. Because 89% of the followed injuries never required surgery, nonoperative observation appears to be a safe and effective management option for clinically occult arterial injuries.

The cornerstone for radiographic evaluation of genitourinary trauma is intravenous pyelography (IVP). Despite its widespread use, however, the indications for emergency IVP in trauma remain controversial. Some authors recommend the use of an IVP for all patients with hematuria, while others are selective, basing their decision on the degree of hematuria or such other factors as the mechanism of injury, physical examination, or the presence of associated injuries. Based on the data reviewed for blunt and penetrating trauma, we recommend that an IVP be performed in: all patients with gross hematuria; all patients who present with pain or tenderness that could be referrable to the genitourinary tract, even in the absence of hematuria; all patients with flank hematoma or ecchymosis; and all patients with penetrating trauma that could reasonably be expected to injure the genitourinary tract. Recently computed tomography (CT) has been proposed for the evaluation of renal trauma. The CT proponents cite superior definition of the extent of renal injury and superior detection of injuries not clinically suspected. Some have proposed the following algorithm, incorporating computed tomography. If an isolated renal injury is suspected clinically, an emergency IVP is performed. If the IVP is normal, expectant conservative treatment follows. If the IVP is abnormal or if the patient has persistent symptoms, an emergency CT scan is performed. Furthermore computed tomography is performed initially in the stable patient with multiple trauma and in the patient with suspected severe renal injury. While this algorithm has not been universally accepted, future studies confirming the theoretical advantages of this approach are anticipated.

We have treated 45 patients with carotid artery injuries--33 caused by penetrating wounds and 12 secondary to blunt trauma. Preoperative angiography is useful in stable patients to rule out associated vascular injuries, and it is crucial for operative planning in cases of blunt trauma. Not unexpectedly, the results of carotid artery repair in neurologically stable patients have been excellent, as have been the results of revascularization in patients with equivocal or less-severe neurologic deficits. This has led us to be aggressive in repair of carotid artery injuries in patients with questionable neurologic deficits. In the eight patients with severe preoperative deficits, one death each followed both ligation and repair, but neurologic improvement was noted in several patients. Distal internal carotid injuries at the base of the skull that were not amenable to direct repair were observed with serial angiograms in four patients with either stabilization or improvement in the intimal injury.

Limb loss is the outcome in one third of previously reported popliteal artery injuries. This report summarizes 83 injuries with an amputation rate of 9.6%. Penetrating traumas accounted for 61 (73%) injuries and blunt traumas for 22 (27%). The incidence of amputation varied with injury type from none in seven stab wounds to three of 19 (15.8%) shotgun wounds. Distal ischemia or a pulse deficit highlights the presence of arterial trauma, and the external wound defines its site in most patients. Urgent operation is indicated by these findings. Equivocal findings suggest less compromised flow, and such patients are managed best by arteriographic confirmation before operation. Early systemic anticoagulation is indicated to decrease distal small-vessel thrombosis. The successful management of these injuries requires early and complete restoration of arterial and venous flow. This is accomplished most effectively by priority definitive reconstruction. Compulsive attention to complete restoration of arterial flow during the initial procedure is mandatory. Resection or bypass of all damaged arterial wall, liberal use of autogenous vein grafts, and repair of concomitant venous injuries enhance continued arterial patency. Routine distal catheter thrombectomy and frequent intraoperative arteriography promote and confirm complete reconstruction. Early performance of four quadrant fasciotomy is indicated if compartmental hypertension is suspected. Thorough debridement of injured and questionably viable soft tissue and adequate fracture stabilization are integral parts of successful revascularization.