Terapia endovascular en trauma periférico: una alternativa a la cirugía abierta tradicional / Endovascular therapy in peripheral trauma: our experience

Resumen Introducción: La terapia endovascular ha demostrado ser una buena alternativa de tratamiento en las enfermedades arteriales y venosas. Asimismo, en trauma vascular periférico constituye una excelente opción, especialmente en sitios anatómicos difíciles de acceder y con lesiones complejas como seudoaneurismas, fístulas arteriovenosas (FAV) o la combinación de ambos, con numerosas ventajas. Objetivo: Evaluar los resultados del tratamiento endovascular en trauma vascular penetrante por agresiones y iatrogenias. Materiales y Método: Revisión retrospectiva de todos los pacientes con trauma vascular periférico sometidos a terapia endovascular. Resultados: Entre abril de 2011 y mayo de 2020 se trataron 30 pacientes, 28 hombres y 2 mujeres. Con edades fluctuantes entre 17 y 84 años. La causa del trauma fue 20 penetrantes y 10 iatrogenias. Los vasos afectados fueron arteria femoral superficial 6, femoral profunda 2, subclavia 9, axilar 1, poplítea 4, ilíacas 1, peronea 1, tibial anterior 5, tronco venoso braquiocefálico 1. Diecisiete pacientes fueron tratados con endoprótesis, 9 con embolización y 4 con cierre percutáneo en relación con catéteres arteriales en subclavia. No hubo mortalidad, pero dos pacientes requirieron reparación abierta: un seudoaneurisma poplíteo gigante y un seudoaneurisma de tibial anterior, en ambos se constató sección completa de ambas arterias. El seguimiento clínico ha sido entre 30 días y 3 años. Conclusiones: En esta serie de casos, la terapia endovascular en lesiones de trauma vascular periférico ofrece excelentes resultados con baja morbimortalidad y permeabilidad aceptable a corto y mediano plazo.

Introduction: Endovascular therapy has proven to be a good treatment alternative in arterial and venous diseases. Likewise, in peripheral vascular trauma it is an excellent option, especially in anatomical sites that are difficult to access and with complex lesions such as pseudoaneurysms, arteriovenous fistulas (AVFs) or the combination of both, with numerous advantages. Aim: To evaluate the results of endovascular treatment in trauma Penetrating vascular injury and iatrogenesis. Materials and Method: Retrospective review of all patients with peripheral vascular trauma undergoing endovascular therapy. Results: Between April 2011 and May 2020, 30 patients were treated, 28 men and 2 women. With fluctuating ages between 17 and 84 years. The cause of the trauma was 20 penetrating and 10 iatrogenic. The affected vessels were superficial femoral artery 6, deep femoral 2, subclavian 9, axillary 1, popliteal 4, iliac 1, peroneal 1, anterior tibial 5, brachiocephalic venous trunk 1. Seventeen patients were treated with endoprosthesis, 9 with embolization and 4 with percutaneous closure in relation to arterial catheters in the subclavian. There was no mortality but two patients required open repair: a giant popliteal pseudoaneurysm and an anterior tibial pseudoaneurysm in which both sections of both arteries were found to be complete. Clinical follow-up was between 30 days and 3 years. Conclusión: In this serie, endovascular therapy in peripheral vascular trauma lesions offers excellent results with low morbidity and mortality and acceptable patency in the short and medium term.

Role of Laparoscopic Exploration Under Local Anesthesia in the Management of Hemodynamically Stable Patients with Penetrating Abdominal Injury.

BACKGROUND: In many trauma centers there is an ongoing controversy over the way of managing patients with penetrating abdominal injuries. This study was constructed to evaluate the role of diagnostic laparoscopy performed with local anesthesia for the management of penetrating abdominal injury. PATIENTS AND METHODS: Thirty hemodynamically stable patients with a penetrating stab wound in the anterior abdominal wall were included in this study after consent was obtained. Laparoscopic explorations were done with the patient having local anesthesia. If there was bleeding or intestinal content in the peritoneal cavity or visible injury to any abdominal organ, the procedure was converted to open exploration. If the peritoneal cavities showed no fluid and there was no injury to the abdominal viscera, the patient was followed up for the next 72 hours. Continuous variables were expressed as mean and standard deviation values. Categorical variables were expressed as frequencies and percentages. Student's t test was used to assess the statistical significance of the difference between the two study groups' means. Fisher's exact test was used to examine the relationship between categorical variables. A significance level of P < .05 was used in all tests. All statistical procedures were carried out using SPSS version 20 for Windows software (IBM, Armonk, NY). RESULTS: From the total of 30 patients who underwent laparoscopic exploration, 13 patients (43.3%) needed open exploration: 11 cases had intrabdominal organ injuries that needed laparotomy, 1 case had intraperitoneal blood collection where the only source of blood was the anterior abdominal wall wound, and 1 case had acute abdominal pain after 48 hours of negative laparoscopic exploration, in which an intestinal tear was found upon re-exploration. For the other 17 (56.7%) cases, 3 cases had no peritoneal penetration, whereas 14 cases had peritoneal penetration without any internal organ injuries, and these patients were followed up and discharged after 2-3 days. CONCLUSIONS: Laparoscopy performed with the patient having local anesthesia is an accurate diagnostic tool in the management of patients with an equivocal penetrating stab wound in the abdominal wall and can reduce the number of patients with negative open exploration.

Female genital mutilation/cutting: knowledge, attitude and training of health professionals in inner city London.

OBJECTIVES: To assess the knowledge, attitude and training on female genital mutilation/cutting (FGM/C) amongst medical and midwifery professionals working in an area of high prevalence of the condition. STUDY DESIGN: Prospective observational study using a questionnaire designed to assess knowledge, attitude and training received by health care professionals on the practice of FGM/C. Factors which may affect knowledge, attitude and training were compared between groups. RESULTS: 92.9% (n=79) questionnaires were returned. All respondents were aware of FGM/C but only 27.8% correctly identified the grade from a simple diagram. Three quarters (72.4% and 77.2% respectively) were aware of the complications of FGM/C and of the legislation in the United Kingdom. Of the respondents, 13.9% agreed that a competent adult should be allowed to consent to FGM/C if requested but only 8.9% agreed that the procedure should be medicalised to reduce the associated morbidity. Less than 25% of respondents had received formal training in recognising or managing this condition. CONCLUSION: Although the majority of respondents were aware of FGM/C, their ability to identify the condition and its associated morbidity remain suboptimal; more training is recommended in larger cities with a higher prevalence of this condition.

Acanthus ebracteatus Vahl. ethanol extract enhancement of the efficacy of the collagen scaffold in wound closure: a study in a full-thickness-wound mouse model.

Acanthus ebracteatus Vahl. is a Thai herb that is effective in wound healing. We sought to quantitatively determine whether or not the combined application of Acanthus ebracteatus Vahl. and a collagen scaffold will increase wound closure and angiogenesis. Balb/c mice (body weight: 22-25 g) were anesthetized with sodium thiopental. The dorsal skin incision measuring 1.5 × 1.5 cm was made and then deepened using scissors to produce a full-thickness incision down to the level of the panniculus carnosus. The size of the wound was approximately 10% of the total body surface area. The collagen sheet was implanted onto the wound. Animals were divided into 4 major groups as follows: wound with normal saline (W-NSS), wound treated with 0.3 g/kg BW of Acanthus ebracteatus Vahl. extract (W-AE (0.3 g/kg.bw)), wound implanted with collagen scaffold (W-Coll), and wound implanted with collagen scaffold and treated with 0.3 g/kg BW of Acanthus ebracteatus Vahl. (W-Coll-AE combination). On day 14, the W-Coll-AE group showed decreased wound areas and increased capillary vascularity (CV) when compared to the other 3 groups, W-NSS, W-AE0.3, and W-Coll. In the present study, the combination of AE0.3 with collagen showed the best effect on skin angiogenesis and promoted wound closure with less neutrophil infiltration.

Anatomic distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark.

OBJECTIVE: The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard. DESIGN: The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis. RESULTS: Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006). CONCLUSIONS: Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.

Microbiological profile and antimicrobial susceptibility in surgical site infections following hollow viscus injury.

INTRODUCTION: The purpose of this study was to assess the microbiological profile, antimicrobial susceptibility, and adequacy of the empiric antibiotic therapy in surgical site infections (SSI) following traumatic hollow viscus injury (HVI). METHODS: This is a retrospective study of patients admitted with an HVI from March 2003 to July 2009. SSI was defined as a wound infection or intra-abdominal collection confirmed by positive cultures and requiring percutaneous or surgical drainage. RESULTS: A total of 91 of 667 (13.6%) patients with an HVI developed an SSI confirmed by positive culture. Mean age was 33.0 +/- 14.1 years, mean Injury Severity Score (ISS) was 17.7 +/- 9.6, 91.2% were male, and 80.2% had sustained penetrating injuries. The SSI consisted of 65 intra-abdominal collections and 26 wound infections requiring intervention. The most commonly isolated species in the presence of a colonic injury was Escherichia coli (64.7%), Enterococcus spp. (41.2%), and Bacteroides (29.4%), and in the absence of a colonic perforation, Enterococcus spp. and Enterobacter cloacae (both 38.9%). Susceptibility rates of E. coli and E. cloacae, respectively, were 38% and 8% for ampicillin/sulbactam, 82% and 4% for cefazolin, 96% and 92% for cefoxitin, with both 92% to piperacillin/tazobactam, and 100% to ertapenem. The initial empirical antibiotic therapy adequately targeted the pathogens in 51.6% of patients who developed an SSI. CONCLUSION: The distribution of the microorganisms isolated from SSIs differed significantly according to whether or not a colonic injury was present. Empiric antibiotic treatment was inadequate in upwards of 50% of patients who developed an SSI. Further investigation is warranted to determine the optimal empiric antibiotic regimen for reducing the rate of postoperative SSI.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I.

BACKGROUND AND OBJECTIVES: This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION: The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION: On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

Manejo conservador de los traumatismos renales por arma blanca. Presentación de dos nuevos casos y revisión de la literatura / Stab wounds of the kidney: conservative management. Two new cases and review of the literature

Introducción: El tratamiento de los traumatismos renales por arma blanca ha sido tradicionalmente quirúrgico. Desde hace más 20 años se aboga por un tratamiento conservador con el fin de evitar laparotomías innecesarias y preservar unidades renales. Los criterios para intervenir de forma urgente o las pautas de seguimiento no están establecidos debido a la falta de estudios de calidad. Material y métodos: Presentamos dos nuevos casos de traumatismo renal por arma blanca en los que se llevó a cabo un manejo conservador y realizamos una revisión de la literatura. Resultados: Los dos pacientes evolucionaron favorablemente, si bien uno de ellos presentó hematuria durante el postoperatorio inmediato y fue necesaria una embolización selectiva de una fístula arterio-venosa. La mayor parte de los artículo se basan en series de casos o estudios observacionales retrosprospectivos. Conclusiones: En los traumatismos renales por arma blanca el diagnóstico es clínico y el estadiaje de las lesiones radiológico con una tomografía computarizada. El manejo conservador es de elección cuando el paciente está estable hemodinámicamente y las lesiones no requieren reparación inmediata. Estos pacientes requieren un seguimiento a largo plazo para monitorizar la aparición de complicaciones. Son necesarios estudios de mayor calidad que aporten una mayor evidencia científica (AU)

Introduction: Stab wounds of the kidney have traditionally been managed by open surgery. Nowadays the conservative management of stab wounds injuries is extended in order to avoid unnecessaries nephrectomies and laparotomies without increasing morbidity and mortality. Although there is no a strong evidence to recommend when to operate or what sort of follow up we must do. Material and methods: We present two new cases of stab wounds injuries managed conservatively. We performed a systematic review of the literature. Results: Both patients evolved favorably although one of them presented hematuria 7 days after the traumatism and we performed an embolization of an arteriovenous fistula. Most of the articles are based on series of cases or retrosprospective studies. Conclusions: The diagnosis and staging of stab wounds of the kidney must be done with clinic and CT scan. Conservative management is required when the patient is not hemodinamically unstable and injuries do not require inmediate repair. These patients require a long term follow up to prevent the appearance of complications. Randomized prospective multicenter trials are needed to support the optimum management for each kidney injury degree (AU)

Ear trauma caused by a yucca plant leaf spine.

Three uncommon cases of ear trauma caused by a yucca plant leaf spine are presented. One patient presented with tympanic perforation and the second with mixed hearing loss after spontaneous closure. The third patient probably had a perilymphatic fistula with subsequent labyrinthitis and hearing loss. Although the yucca is a ubiquitous plant, to the best of our knowledge, such incidents have not been previously reported.

Trans-anal rectal injuries.

INTRODUCTION: The diagnosis of trans-anal rectal injuries is usually delayed because of the patient's denial. Some of these injuries are self-inflicted or caused by criminal assault, leading to delayed presentation. We aimed to study the causes, clinical presentation, management and clinical outcome of transanal rectal injuries. METHODS: The records of 12 patients (nine males) with a median age of 36.5 (range 20-64) years, had trans-anal rectal injury and were treated between 1993 and 2006 at Al-Ain Hospital, were reviewed. RESULTS: Injury was caused by a fall on a sharp object in five patients, by a rectal foreign body in two patients, by a compressed air hose in two patients, by sexual assault in two patients, and by rectal cleansing enema in one patient. Seven patients presented two hours after the injury, four patients within 8-24 hours, and one sexually-assaulted patient presented after seven days. Injuries were in the anterior rectal wall in seven, in the rectosigmoid junction in three, and in the anorectal region in two patients. Ten patients presented with peritonitis, four were in shock, seven had bleeding per rectum, and two had a weak sphincter. The complication rate was significantly higher in the colostomy patients compared with primary repair (5/6 compared with 0/6, p-value is less than 0.02, Fisher's exact test). All patients survived. The median (range) hospital stay was ten (9-72) days. CONCLUSION: Diagnosis of trans-anal rectal injuries is usually delayed because of late presentation. Sexual assault should be suspected following rectal injuries. Colostomy is not always mandatory.

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds.

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries?

BACKGROUND: Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. METHODS: This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. RESULTS: There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. CONCLUSIONS: Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.

Laceration management.

In 1996, almost 11 million lacerations were treated in emergency departments throughout the United States. Although most lacerations heal without sequelae regardless of management, mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality. The goals of wound management are simple: avoid infection and achieve a functional and aesthetically pleasing scar. Recent US Food and Drug Administration approval of tissue adhesives has significantly expanded clinicians' wound closure options and improved patient care. We review the general principles of wound care and expand on the use of tissue adhesives for laceration repair.

Venomous marine creatures.

BACKGROUND: Many venomous marine creatures inhabit Australian waters, causing significant morbidity and occasional fatalities. No antivenom is available for most of these creatures. Little is known about the venom or syndromes produced by many of these creatures. OBJECTIVE: This article discusses the features of envenomation by some of the more commonly encountered venomous marine creatures, and the recommended first aid and medical management of such envenomations. DISCUSSION: The information contained within this article is intended to provide the reader with an overview of some of the more common marine envenomations, and hopefully with the knowledge to effectively manage such problems.

Heridas penetrantes cardiacas / Cardiac penetrating wounds

La herida penetrante cardíaca ha aumentado en frecuencia como resultado del aumento de la agresividad y de los accidentes automovilísticos e industriales. La experiencia que ello ha significado y la derivada de los conflicots bélicos ha ido mejorando los índicces de recuperación. Para graficar la magnitud del problema en el área occidente del Servicio Metropolitano de Salud se realizó un estudio prospectivo de los pacientes atendidos con este diagnóstico en el Hospital San Juan de Dios durante un período de dos años (junio de 1993 a julio de 1995). Se reunieron 28 pacientes en los que predominaron los hombres (27). El promedio de dad fue de 27 años y la causa más frecuente fue la agresión con arm blanca (89 por ciento). El diagnóstico clínico fue seguido de una toracotomía de urgencia, salvp uno que falleció antes de llegar al pabellón y la vía preferentemente empleada fue la intercostal ánterolateral (85 por ciento). Se realizó cardiorrafia de la cavidad comprometida, que en este grupo fue el ventrículo izquierdo preferentemente. Tanto el inreso en shock hipovolémico severo (17 por ciento), como el 14 por ciento del daño hipóxico del SNC como complicación, sugieren que pudiera haber retraso en el traslado. Se recuperaron 18 pacientes o dicho de otro modo, la letalidad fue de 35,7 por ciento. El estudio cardiológico dirigido previo al alta demostró un 22,3 por ciento de secuelas

Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest.

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eight-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.