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Review the radiologic findings and clinical significance of tension pneumoperitoneum.Imaging case presented to radiology during patient's prolonged and complicated hospital stay.Tension pneumoperitoneum associated with barotrauma is a rare, but potentially life threatening complication of mechanical ventilation. The radiologist should be able to recognize the imaging findings associated with tension pneumoperitoneum in order to assist in diagnosis of this potentially reversible entity.

Gaining hemostatic control of lethal vascular injuries sustained in combat using topical agents remains a challenge. Recent animal testing using a lethal arterial injury model has demonstrated that QuikClot zeolite granules (QCG) and the HemCon chitosan bandage (HC) are not capable of providing hemostasis and improving survival over the Army gauze field bandage (AFB). We have developed a new hemostatic agent consisting of a granular combination of a smectite mineral and a polymer (WoundStat) capable of producing hemostasis in the face of high-pressure arterial bleeding. We compared the performance of WoundStat (WS) to QCG, HC, AFB, and the new QuikClot zeolite Advance Clotting Sponge (ACS) in a lethal vascular injury model.Hemostatic agents were tested using a lethal femoral artery vascular injury model. Twenty-five (5 per group) male swine (42 kg +/- 3 kg) were anesthetized, instrumented, and splenectomized. A lethal femoral artery injury was produced by creating a 6-mm arteriotomy in the vessel. After 45 seconds of hemorrhage, animals were randomized to be treated with AFB (control group), HC, QCG, ACS, or WS. Pressure (200 mm Hg) was applied over the product in the wound for 3 minutes. A second application and 3 additional minutes of pressure was provided if hemostasis was not achieved. Fluid resuscitation was begun at the time of application with 500 mL of Hextend, followed by lactated Ringer's solution at 100 mL/min to achieve and maintain a postapplication mean arterial blood pressure of 65 mm Hg. Animals were observed for 180 minutes or until death. Primary endpoints were survival, survival time, post-treatment blood loss, and amount of resuscitation fluid.All animals treated with WS survived to 180 minutes and required only a single application. No animal in the AFB, QCG, or ACS group survived. One animal in the HC group survived. Survival (p0.05) and survival times (p0.0001) for WS animals were significantly greater than for all other groups. No significant difference in survival or survival time existed between the AFB, QCG, ACS, or HC groups. Post-treatment blood loss (p = 0.0099) and postresuscitation fluid volume (p = 0.006) was significantly less for animals treated with WS than for all other groups. No significant difference in these parameters existed between the AFB, QCG, ACS, and HC groups.WS was superior to the other hemostatic agents tested in this study of lethal arterial vascular injury. Additional study is warranted on this agent to determine its potential for use in combat and civilian trauma.

Background Amniotic band sequence (ABS) is a rare disorder that can result in a wide spectrum of congenital craniofacial, limb, trunk, and viscera deformities. One of the more rare manifestations of ABS is intrauterine fetal decapitation. Case Report This case report presents the ultrasonographic diagnosis of first-trimester intrauterine fetal demise resulting from decapitation secondary to amniotic band sequence. Why Should an Emergency Physician Be Aware of This? This case report presents a rare and atypical presentation of intrauterine demise valuable for an emergency physician to recognize while performing or reviewing pelvic ultrasounds. It is important for the clinician to understand and counsel the patient that subsequent pregnancies will not be at increased risk due to a prior miscarriage from ABS, as opposed to other etiologies of first-trimester spontaneous abortion.

Knowledge of central venous pressure (CVP) is considered valuable in the assessment and treatment of various states of critical illness and injury. We tested a noninvasive means of determining CVP (NICVP) by monitoring upper arm blood flow changes in response to externally applied circumferential pressure to the upper arm veins. Thirty-six patients who were undergoing CVP monitoring as part of their care had NICVP determined and compared with CVP. Volume changes were measured in the upper arm using tetra-polar impedance plethysmography underneath a blood pressure cuff. The cuff was inflated over 5 s to a pressure greater than CVP but less than diastolic arterial pressure. After 45 to 60 s, the cuff was rapidly deflated. Noninvasive CVP was determined as the cuff pressure noted at the maximum derivative of the volume increase under the cuff during deflation. Noninvasive CVP was then compared with invasively measured CVP taken during the same period by Bland-Altman analysis. A total of 108 trials (three per subject) were performed on 36 patients. Mean bias was j0.26 mmHg (95% confidence interval (CI): j0.67, 0.15). Limits of agreement were j2.7 and 2.2 mmHg with the 95% CI for the lower limit of agreement (j3.4, j2.0 mmHg) and for the upper limit of agreement (1.5, 2.9 mmHg). Correlation between CVP and NICVP was 0.95 (95% CI: 0.93 to 0.97; P G 0.0001). Noninvasive CVP as determined in this study may be a clinically useful substitute for traditional CVP measurement and may offer a tool for early diagnosis and treatment of acute states in which knowledge of CVP would be helpful. KEYWORDS—Monitoring, catheter, critical illness, injury, volume assessment

The resonant Raman enhancement of hemoglobin (Hb) in the Q band region allows simultaneous identification of oxy- and deoxy-Hb. The heme vibrational bands are well known at 532 nm, but the technique has never been used to determine microvascular Hb oxygen saturation (So2) in vivo. We implemented a system for in vivo noninvasive measurements of So2. A laser light was focused onto areas of 15–30 μm in diameter. Using a microscope coupled to a spectrometer and a cooled detector, Raman spectra were obtained in backscattering geometry. Calibration was performed in vitro using blood at several Hb concentrations, equilibrated at various oxygen tensions. So2 was estimated by measuring the intensity of Raman signals (peaks) in the 1,355- to 1,380-cm−1 range (oxidation state marker band ν4), as well as from the ν19 and ν10 bands (1,500- to 1,650-cm−1 range). In vivo observations were made in microvessels of anesthetized rats. Glass capillary pathlength and Hb concentration did not affect So2 estimations from Raman spectra. The Hb Raman peaks observed in blood were consistent with earlier Raman studies using Hb solutions and isolated cells. The correlation between Raman-based So2 estimations and So2 measured by CO-oximetry was highly significant for ν4, ν10, and ν19 bands. The method allowed So2 determinations in all microvessel types, while diameter and erythrocyte velocity could be measured in the same vessels. Raman microspectroscopy has advantages over other techniques by providing noninvasive and reliable in vivo So2 determinations in thin tissues, as well as in solid organs and tissues in which transillumination is not possible.