Imaging and Endovascular Treatment of Bleeding Pelvic Fractures: Review Article.

Pelvic fractures are potentially life-threatening injuries with high mortality rates, mainly due to intractable pelvic arterial bleeding. However, concomitant injuries are frequent and may also be the cause of significant blood loss. As treatment varies depending on location and type of hemorrhage, timely imaging is of critical importance. Contrast-enhanced CT offers fast and detailed information on location and type of bleeding. Angiography with embolization for pelvic fracture hemorrhage, particularly when performed early, has shown high success rates as well as low complication rates and is currently accepted as the first method of bleeding control in pelvic fracture-related arterial hemorrhage. In the current review imaging workup, patient selection, technique, results and complications of pelvic embolization are described.

Washing or filtering of blood products does not improve outcome in a rat model of trauma and multiple transfusion.

BACKGROUND: Transfusion is associated with organ failure and nosocomial infection in trauma patients, which may be mediated by soluble bioactive substances in blood products, including extracellular vesicles (EVs). We hypothesize that removing EVs, by washing or filtering of blood products, reduces organ failure and improves host immune response. MATERIALS AND METHODS: Blood products were prepared from syngeneic rat blood. EVs were removed from RBCs and platelets by washing. Plasma was filtered through a 0.22-µm filter. Rats were traumatized by crush injury to the intestines and liver, and a femur was fractured. Rats were hemorrhaged until a mean arterial pressure of 40 mm Hg and randomized to receive resuscitation with standard or washed/filtered blood products, in a 1:1:1 ratio. Sham controls were not resuscitated. Ex vivo whole blood stimulation tests were performed and histopathology was done. RESULTS: Washing of blood products improved quality metrics compared to standard products. Also, EV levels reduced by 12% to 77%. The coagulation status, as assessed by thromboelastometry, was deranged in both groups and normalized during transfusion, without significant differences. Use of washed/filtered products did not reduce organ failure, as assessed by histopathologic score and biochemical measurements. Immune response ex vivo was decreased following transfusion compared to sham but did not differ between transfusion groups. CONCLUSION: Filtering or washing of blood products improved biochemical properties and reduced EV counts, while maintaining coagulation abilities. However, in this trauma and transfusion model, the use of optimized blood components did not attenuate organ injury or immune suppression.

Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury.

This study aims to (1) investigate the neuropathology of mild to severe pediatric TBI and (2) elucidate the predictive value of conventional and innovative neuroimaging for functional outcome. Children aged 8-14 years with trauma control (TC) injury (n = 27) were compared to children with mild TBI and risk factors for complicated TBI (mildRF+, n = 20) or moderate/severe TBI (n = 17) at 2.8 years post-injury. Neuroimaging measures included: acute computed tomography (CT), volumetric analysis on post-acute conventional T1-weighted magnetic resonance imaging (MRI) and post-acute diffusion tensor imaging (DTI, analyzed using tract-based spatial statistics and voxel-wise regression). Functional outcome was measured using Common Data Elements for neurocognitive and behavioral functioning. The results show that intracranial pathology on acute CT-scans was more prevalent after moderate/severe TBI (65%) than after mildRF+ TBI (35%; p = .035), while both groups had decreased white matter volume on conventional MRI (ps ≤ .029, ds ≥ -0.74). The moderate/severe TBI group further showed decreased fractional anisotropy (FA) in a widespread cluster affecting all white matter tracts, in which regional associations with neurocognitive functioning were observed (FSIQ, Digit Span and RAVLT Encoding) that consistently involved the corpus callosum. FA had superior predictive value for functional outcome (i.e. intelligence, attention and working memory, encoding in verbal memory and internalizing problems) relative to acute CT-scanning (i.e. internalizing problems) and conventional MRI (no predictive value). We conclude that children with mildRF+ TBI and moderate/severe TBI are at risk of persistent white matter abnormality. Furthermore, DTI has superior predictive value for neurocognitive out-come relative to conventional neuroimaging.

Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen.

BACKGROUND: This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This "open abdomen" must then be temporarily closed. However, the FC rate varies between techniques. METHODS: The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) "open abdomen," "fascial closure," "vacuum," "reapproximation," and "ventral hernia." Open abdomen was defined as "the inability to close the abdominal fascia after laparotomy." Two reviewers independently extracted data from original articles by using a predefined checklist. RESULTS: The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). CONCLUSIONS: These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.