Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report.

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.

Can we refine the management of blunt liver trauma?

AIM: To describe the management of blunt liver injury and to study the potential relation between delayed complications, type of trauma mechanisms and liver lesions. PATIENTS AND METHODS: This is a retrospective single center study including 116 consecutive patients admitted with blunt liver injury between 2007 and 2015. RESULTS: Initial CT-scan identified an active bleeding in 33 (28%) patients. AAST (American Association for the Surgery of Trauma) grade was 1 to 3 in 82 (71%) patients and equal to 5 in 15 (13%) patients. Eighty (69%) patients had NOM, with a success rate of 96%. Other abdominal organ lesions were associated to invasive initial management. A follow-up CT-scan was useful to detect hepatic and extra-hepatic complications (46 complications in 80 patients), even without clinical or biological abnormalities. Subsequent hepatic complications such as bleeding, pseudo aneurysms, biloma and biliary peritonitis developed in 15 patients and were associated with the severity of blunt liver injury according to AAST classification (3.7±1.0 vs. 3.0±1.1, P=0.010). Total biliary complications occurred in 13 patients and were significantly more frequently observed in patients with injury of central segments 1, 4 and 9 (69% vs. 36%, P=0.033). CONCLUSIONS: Non-operative management is possible in most blunt liver injury with a success rate of 96%. A systematic CT-scan should be advocated during follow-up, especially when AAST grade is equal or superior to 3. Biliary complications should be suspected when lesions involve segments 1, 4 and 9.

[Opioid-sparing effect of ketamine during tonsillectomy in children]. / Effet d'épargne morphinique de la kétamine au cours de l'amygdalectomie chez l'enfant.

INTRODUCTION: In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy. METHODS: We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage. RESULTS: No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects. CONCLUSION: These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.