Intestinal obstruction caused by small bowel entrapment within a lumbar fracture: A case report.

INTRODUCTION: Intestinal obstruction associated with traumatic vertebral fracture is extremely rare. We report a case of obstructive small bowel injury caused by entrapment of the small intestine at the fracture site of the 5th lumbar vertebra due to trauma. CASE PRESENTATION: A 55-year-old man fell from a height of 4 m and visited the emergency room of a local hospital with complain of back pain. During the examination, a 5th lumbar vertebral body fracture and left psoas muscle hematoma were observed, and the patient was admitted to the neurosurgery department for conservative treatment. The patient received conservative treatment for 2 days, but new symptoms of intestinal obstruction and fever occurred. A neurosurgeon at the hospital suspected duodenal perforation and transferred the patient to the regional trauma center for treatment. Our medical staff reviewed the patient's symptoms and imaging data and decided to perform an emergency operation because of small bowel entrapment in the 5th lumbar vertebrae fracture and perforation of the small intestine. We found that the small bowel, approximately 160 cm below the ligament of Treitz, was incarcerated at the 5th lumbar vertebral fracture site. After careful manual reduction of the entrapment of the small intestine, a small bowel resection of 25 cm, including the injury site, was performed with anastomosis. CONCLUSION: If symptoms of intestinal obstruction are observed in patients with traumatic spinal injury, medical staff must consider the exceedingly rare possibility of bowel entrapment.

Endovascular treatment of traumatic renal artery pseudoaneurysm with a Stanford type A intramural haematoma: A case report.

BACKGROUND: Aortic intramural hematoma (IMH) associated with aortic branch tear and intramurally located pseudoaneurysm after blunt trauma has not been reported. Here, we report a case of progressive type A aortic IMH associated with a pseudoaneurysm arising from the injured proximal renal artery after blunt trauma. CASE SUMMARY: During logging operations, a 66-year-old man experienced blunt force trauma after being injured by a fallen tree. He arrived at our trauma center with a left flank pain complaint. Computed tomography (CT) revealed a pseudoaneurysm arising from the proximal renal artery (localized within the aortic media) and Stanford type A IMH. A covered stent was deployed along the left main renal artery, bridging the pseudoaneurysm and covering the parent artery, successfully excluding the pseudoaneurysm as confirmed using aortography. However, although the degree of the pseudoaneurysm decreased, follow-up CT revealed remnant pseudoaneurysm, likely caused by an endoleak. Subsequently, a covered stent was additionally installed through the previously deployed covered stent. Successful exclusion of the pseudoaneurysm was confirmed using final aortography. In the 7-mo follow-up CT scan, the IMH and pseudoaneurysm completely disappeared with no evidence of stent-related complications. CONCLUSION: Endovascular treatment such as stent-graft placement can be an effective and safe treatment for traumatic renal artery injury.

Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution.

Background: We aimed to investigate the outcomes after delayed management of ≥ Grade II blunt traumatic thoracic aortic injury (BTAI). Methods: Between January 2005 and December 2019, we retrospectively reviewed the medical records of 21 patients with ≥ Grade II thoracic aortic injury resulting from blunt trauma. Twelve patients underwent observation for the injury, whereas nine patients were transferred immediately after the diagnosis. Patients were divided into a nonoperative management group (n = 7) and delayed repair group (n = 5) based on whether they underwent thoracic endovascular aneurysm repair or surgery. Results: The most common dissection type was DeBakey classification IIIa (n = 9). Five patients underwent delayed surgery (including aneurysm repair), with observation periods ranging from 1 day to 36 months. The delayed repair group exhibited higher injury severity scores than the nonoperative management group (n = 7). The nonoperative management group was followed-up with blood pressure management without a change in status for a period ranging from 3 to 96 months. Conclusions: Our findings indicated that conservative management may be appropriate for select patients with Grade II/III BTAI, especially those exhibiting hemodynamic stability with anti-impulse therapy and minimally sized pseudoaneurysms. However, further studies are required to identify the risk factors for injury progression and long-term outcomes.

Risk factors for ventilator-associated pneumonia in trauma patients with torso injury: a retrospective single-center study.

OBJECTIVE: We aimed to identify the risk factors for ventilator-associated pneumonia in patients admitted to critical care after a torso injury. METHODS: We retrospectively evaluated 178 patients with torso injury aged >15 years who were intubated in the emergency room and placed on a mechanical ventilator after intensive care unit (ICU) admission, survived for >48 hours, had thoracic and/or abdominal injuries, and had no end-stage renal disease. We compared clinico-laboratory variables between ventilator-associated pneumonia (n = 54, 30.3%) and non-ventilator-associated pneumonia (n = 124, 69.7%) groups. Risk factors for ventilator-associated pneumonia were assessed using multivariable logistic regression analysis. RESULTS: Ventilator-associated pneumonia was associated with a significantly longer stay in the ICU (11.3 vs. 6.8 days) and longer duration of mechanical ventilation (7 vs. 3 days). Injury Severity Score (adjusted odds ratio [AOR]: 1.048; 95% confidence interval [CI]: 1.008-1.090), use of vasopressors (AOR: 2.541; 95% CI: 1.121-5.758), and insertion of a nasogastric tube (AOR: 6.749; 95% CI: 2.397-18.999) were identified as independent risk factors of ventilator-associated pneumonia. CONCLUSION: Ventilator-associated pneumonia in patients with torso injury who were admitted to the ICU was highly correlated with Injury Severity Score, use of vasopressors, and insertion of a nasogastric tube.

Effect of weather variables on the incidence of trauma: A retrospective study at a single tertiary hospital center for 4 years.

ABSTRACT: The occurrence of trauma is associated with various factors, including weather. We aimed to elucidate the relationship between local weather factors and the incidence of trauma to effectively manage and treat patients in a community setting. A retrospective study was conducted at a single center from January 2016 to December 2019. The study participants were trauma patients in the Cheongju area where the regional trauma center is located. Weather data including average daily temperature (°C), rainfall duration (hours), amount of rainfall (mm), average relative humidity (%), wind speed (m/s), and total sunlight hours per day were collected. One-way analysis of variance, correlation analysis, and linear regression analysis were performed. The average age of the participants (n = 3352) was 52.69 years. As regards seasonal difference in the incidence of trauma, there were more patients in spring than in winter (2.42/day vs 2.06/day, P = .05). The highest number of average daily trauma incidents occurred from April to June, and the difference between this value and that from January to February was significant (F = 2.20, P = .01). According to the distributed lag nonlinear model (DLnM), the relative risk is greater than 1 when the mean temperature is high (>15°C) compared to when the temperature is low (<15°C). The trauma patient prevalence was the highest at high wind speed (4.5 m/s). When the total amount of sunlight was long (>Ref. 8 hours), the trauma patient prevalence was relatively higher than the median value (lag = 0). DLnM analysis results showed that the relative risk of trauma patients increased as the amount of precipitation increased, and the incidence of trauma increased when the relative humidity was 40% to 50%. Multiple linear regression analysis revealed that high average daily temperatures and long average daily total sunlight hours resulted in an increased incidence of trauma (F = 6.605, P < .001). An increase in temperature, an increase in the daily sunlight hours, an increase in rainfall, high wind speed, and relative humidity of 40% to 50% are associated with a relatively high risk of trauma.

Risk factors for acute kidney injury in critically ill patients with torso injury: A retrospective observational single-center study.

ABSTRACT: Acute kidney injury (AKI) is common in trauma patients and associated with poor outcomes. Identifying AKI risk factors in trauma patients is important for risk stratification and provision of optimal intensive care unit (ICU) treatment. This study identified AKI risk factors in patients admitted to critical care after sustaining torso injuries.We performed a retrospective chart review involving 380 patients who sustained torso injuries from January 2016 to December 2019. Patients were included if they were aged >15 years, admitted to an ICU, survived for >48 hours, and had thoracic and/or abdominal injuries and no end-stage renal disease. AKI was defined according to the Kidney Disease Improving Global Outcomes definition and staging system. Clinical and laboratory variables were compared between the AKI and non-AKI groups (n = 72 and 308, respectively). AKI risk factors were assessed using multivariate logistic regression analysis.AKI occurred in 72 (18.9%) patients and was associated with higher mortality than non-AKI patients (26% vs 4%, P < .001). Multivariate logistic regression analysis identified bowel injury, cumulative fluid balance >2.5 L for 24 hours, lactate levels, and vasopressor use (adjusted odds ratio: 2.953, 2.058, 1.170, and 2.910; 95% confidence interval: 1.410-6.181, 1.017-4.164, 1.019-1.343, and 1.414-5.987; P = .004, .045, .026, and .004, respectively) as independent risk factors for AKI.AKI in patients admitted to the ICU with torso injury had a substantial mortality. Recognizing risk factors at an early stage could aid risk stratification and provision of optimal ICU care.

Management for traumatic hepatic injury diagnosed by contrast-enhanced ultrasonography in a patient with an occluded coeliac axis: a case report.

Transcatheter arterial embolization (TAE) is the standard of care for haemodynamically-stable patients with blunt hepatic injury but it is sometimes impossible due to unfavourable vascular anatomies. This case report describes a 43-year-old male patient with abdominal pain following a motorcycle accident. Based on computed tomography (CT) findings, he was diagnosed with high-grade hepatic injury with coeliac axis stenosis (CAS) due to compression by the median arcuate ligament, and an aberrant right hepatic artery. Contrast-enhanced ultrasonography (CEUS) demonstrated multiple high echogenic tubular and ovoid structures suggestive of active bleeding within the injured liver area. Angiography revealed unique interlobar and intrahepatic collateral vessels between the right and left hepatic arteries. Liver haemorrhages were also identified. Catheterization of the feeding arteries through the collateral pathway was unsuccessful, so a decision was made to cannulate the stenotic portion of the coeliac trunk with a 5-Fr Yashiro catheter. After several attempts, the microcatheter was successfully advanced coaxially into the common hepatic artery. Embolization was performed with a 1:2 mixture of N-butyl cyanoacrylate and iodized oil. Successful haemostasis was confirmed following TAE. CEUS helped clinicians identify active bleeding following traumatic solid organ injury. TAE was a safe and effective treatment strategy. Before performing TAE, attention should be given to the presence of CAS associated with compression by the median arcuate ligament.

Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma: a multicenter trial in Korea.

PURPOSE: Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma. METHODS: From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated. RESULTS: Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate. CONCLUSION: Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.

Pneumatic Colorectal Injury Caused by High Pressure Compressed Air.

The pneumatic colorectal injury caused by high pressure compressed air are rare and can be fatal. Herein, we present a case of 45-year-old male who developed sudden onset of severe abdominal pain after cleaning the dust on his pants with high pressure compressed air gun dust cleaner. Emergent exploratory laparotomy was done which findings are a huge rectal perforation with multiple serosal and subserosal tear in sigmoid to splenic flexure of colon. Anterior resection with left hemicolectomy, and temporary transverse colostomy was performed. Postoperative course was uneventful. Recently, prognosis is generally favorable because of prompt diagnosis and emergent surgical management.

Antibiotic use in patients with abdominal injuries: guideline by the Korean Society of Acute Care Surgery.

PURPOSE: A task force appointed by the Korean Society of Acute Care Surgery reviewed previously published guidelines on antibiotic use in patients with abdominal injuries and adapted guidelines for Korea. METHODS: Four guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Five topics were considered: indication for antibiotics, time until first antibiotic use, antibiotic therapy duration, appropriate antibiotics, and antibiotic use in abdominal trauma patients with hemorrhagic shock. RESULTS: Patients requiring surgery need preoperative prophylactic antibiotics. Patients who do not require surgery do not need antibiotics. Antibiotics should be administered as soon as possible after injury. In the absence of hollow viscus injury, no additional antibiotic doses are needed. If hollow viscus injury is repaired within 12 hours, antibiotics should be continued for ≤ 24 hours. If hollow viscus injury is repaired after 12 hours, antibiotics should be limited to 7 days. Antibiotics can be administered for ≥7 days if hollow viscus injury is incompletely repaired or clinical signs persist. Broad-spectrum aerobic and anaerobic coverage antibiotics are preferred as the initial antibiotics. Second-generation cephalosporins are the recommended initial antibiotics. Third-generation cephalosporins are alternative choices. For hemorrhagic shock, the antibiotic dose may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. CONCLUSION: Although this guideline was drafted through adaptation of other guidelines, it may be meaningful in that it provides a consensus on the use of antibiotics in abdominal trauma patients in Korea.

Right-sided diaphragmatic rupture in a poly traumatized patient.

Traumatic diaphragmatic rupture (TDR) is uncommon, and may be associated with other severe life-threatening injuries after blunt trauma. Recently, we experienced a right-sided TDR patient with other multiple life-threatening injuries. A 59-year-old female inflicted with a right-sided TDR accompanied by herniated liver was treated with thoracoscopic exploration. We successfully managed associated life-threatening injuries such as traumatic brain injury and pelvic bone fractures with bleeding, simultaneously.

Colorectal Perforation After Anorectal Manometry for Low Anterior Resection Syndrome.

We experienced 3 cases of manometry-induced colon perforation. A 75-year-old man (case 1) underwent anorectal manometry (ARM) 3 years after radiotherapy for prostate cancer and a laparoscopic intersphincteric resection for rectal cancer. A 70-year-old man (case 2) underwent ARM 3 months after conventional neoadjuvant chemoradiotherapy and a laparoscopic low anterior resection for rectal cancer. A 78-year-old man (case 3) underwent ARM 2 months after a laparoscopic intersphincteric resection for rectal cancer. In all cases, a colon perforation with fecal peritonitis occurred. All were treated successfully using prompt and active operations and were discharged without any complications. ARM with a balloon, as a measure of rectal compliance, should be performed 2 months or longer after surgery. If a perforation occurs, prompt and active surgical intervention is necessary due to the high possibility of extensive fecal peritonitis.

The Ability of the Acute Physiology and Chronic Health Evaluation (APACHE) IV Score to Predict Mortality in a Single Tertiary Hospital.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II model has been widely used in Korea. However, there have been few studies on the APACHE IV model in Korean intensive care units (ICUs). The aim of this study was to compare the ability of APACHE IV and APACHE II in predicting hospital mortality, and to investigate the ability of APACHE IV as a critical care triage criterion. METHODS: The study was designed as a prospective cohort study. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test respectively. We also calculated the standardized mortality ratio (SMR). RESULTS: The APACHE IV score, the Charlson Comorbidity index (CCI) score, acute respiratory distress syndrome, and unplanned ICU admissions were independently associated with hospital mortality. The calibration, discrimination, and SMR of APACHE IV were good (H = 7.67, P = 0.465; C = 3.42, P = 0.905; AUROC = 0.759; SMR = 1.00). However, the explanatory power of an APACHE IV score >93 alone on hospital mortality was low at 44.1%. The explanatory power was increased to 53.8% when the hospital mortality was predicted using a model that considers APACHE IV >93 scores, medical admission, and risk factors for CCI >3 coincidentally. However, the discriminative ability of the prediction model was unsatisfactory (C index <0.70). CONCLUSIONS: The APACHE IV presented good discrimination, calibration, and SMR for hospital mortality.

Appendiceal transection associated with seat belt restraint.

The seat belt is designed for safety in a motor vehicle and should be worn to prevent severe injuries. But, the seat belt itself can be an injury factor in combination with deceleration forces applied to fixation points of mobile viscera. Here, we present a 23-year-man with traumatic transection of the appendix, highly mobile viscera, following seat belt injury.

Endovascular stent graft for traumatic splenic vein aneurysm via percutaneous transsplenic access.

Traumatic splenic vein aneurysm (SVA) is an extremely rare entity. Traditionally, treatment varied from noninvasive followup to aneurysm excision with splenectomy. However, there has been no prior report of traumatic SVA treated with endovascular stent graft for SVA via percutaneous transsplenic access. Therefore, we report the case of a 56-year-old man successfully treated with endovascular stent graft for traumatic SVA via percutaneous transsplenic access.

An ent-kaurane diterpenoid from Croton tonkinensis induces apoptosis by regulating AMP-activated protein kinase in SK-HEP1 human hepatocellular carcinoma cells.

Hepatocellular carcinoma (HCC) is the most common type of liver cancer with high mortality worldwide. Traditional chemotherapy for HCC is not widely accepted by clinical practitioners because of its toxic side effects. Thus, there is a need to identify chemotherapeutic drugs against HCC. AMP-activated protein kinase (AMPK) is a biologic sensor for cellular energy status that acts a tumor suppressor and a potential cancer therapeutic target. The traditional Vietnamese medicinal plant Croton tonkinensis shows cytotoxicity in various cancer cells; however, its anticancer mechanism remains unclear. In this study, we determined whether the ent-kaurane diterpenoid ent-18-acetoxy-7ß-hydroxy kaur-15-oxo-16-ene (CrT1) isolated from this plant plays a role as a chemotherapeutic drug targeting AMPK. CrT1 blocked proliferation in dose- and time-dependent manners in human hepatocellular carcinoma SK-HEP1 cells. CrT1 induced sub-G(1) arrest and caspase-dependent apoptosis. CrT1 activated caspase-3, -7, -8, -9, and poly(ADP-ribose) polymerase, and its effect was inhibited by z-VAD-fmk suppressing caspase-3 cleavage. CrT1 induced increases in p53 and Bax levels but decreased Bcl(2) levels. In addition, CrT1 resulted in increased translocation of cytochrome c into the cytoplasm. We showed that CrT1-activated AMPK activation was followed by modulating the mammalian target of rapamycin/p70S6K pathway and was inactivated by treating cells with compound C. Treatment with CrT1 and aminoimidazole carboxamide ribonucleotide (AICAR) synergistically activated AMPK. CrT1-induced AMPK activation regulated cell viability and apoptosis. These results suggest that CrT1 is a novel AMPK activator and that AMPK activation in SK-HEP1 cells is responsible for CrT1-induced anticancer activity including apoptosis.