[Thromboembolic risk in repatriated patients with traumatic lower-limb injuries]. / Risque thromboembolique chez les patients traumatisés des membres inférieurs rapatriés.

INTRODUCTION: Venous thromboembolism (VTE) is a public health problem. Medical repatriation of patients with traumatic lower-limb injuries is common. There are no specific recommendations for the prevention of deep vein thrombosis (DVT). The main objective was to determine the incidence of VTE in this high-risk population and to determine associated risk factors. MATERIALS AND METHODS: This was a prospective study including patients repatriated to France following lower-limb trauma and hospital discharge. A physical examination and a venous ultrasound were systematically performed on arrival. Reasons for repatriation, methods of VTE prevention and risk factors for VTE were studied. The positive diagnosis of deep venous thrombosis (DVT) was done by Doppler ultrasound. RESULTS: Fifty-two patients with lower-limb trauma were included. Six cases of DVT, four asymptomatic and two symptomatic with pulmonary embolisms were diagnosed. Two patients with asymptomatic DVT did not have preventive anticoagulation. No patient with preventive anticoagulation had symptomatic DVT. Smoking and the absence of preventive anticoagulation were significant risk factors for VTE. DISCUSSION: Repatriation of patients with lower-limb trauma in discharge is associated with an increased risk of VTE. Preventive anticoagulation appears to be effective in preventing DVT. Systematic Doppler imaging can reveal asymptomatic DVT. Our study did not evaluate specifically the interest of venous compression associated to preventive anticoagulation for VTE prevention. Specific recommendations on VTE prevention during repatriation of patients with lower-limb trauma are needed. CONCLUSION: Preventive anticoagulation should be systematically discussed during repatriation of patients with lower-limb trauma, in the absence of major bleeding risk. Due to the existence of asymptomatic DVT, venous Doppler ultrasound should also be systematically discussed despite the absence of official recommendations.

[Lung hernia provoked by a cough fit]. / Hernie pulmonaire intercostale secondaire à un effort de toux.

Lung hernias are rare and their pathogenesis is few described. They are defined as the protrusion of lung parenchyma through the chest wall: intercostal space, inter-costo-clavicular, supra-clavicular or diaphragmatic hiatus. Lung hernias are classically divided into congenital and acquired hernias. Those are usually post-traumatic or post-surgical but can be provoked by cough. Clinical diagnosis is often evident but is confirmed by chest radiograph and especially computed tomography. Major risks are lung incarceration and necrosis but also ventilatory distress due to paradoxical respiration, in case of large defect. Treatment is first and foremost surgical but debated and should consider the localization, the size, the length of evolution and the possible infectious context. We report the case of a right basi-thoracic lung hernia induced by a cough fit, in a patient with chronic bronchitis.

Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons.

In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.