Non-perforated Traumatic Pneumoperitoneum in Maxillofacial Trauma: A Compelling Case Report.

Pneumoperitoneum typically results from intraabdominal gas due to gastrointestinal perforation, with exploratory laparotomy serving as the standard management. While non-surgical causes are well established, instances where pneumoperitoneum lacks an identifiable cause even after laparotomy are sparsely documented. Here, we present a case involving a 22-year-old male who, following a high-velocity road traffic injury resulting in a panfacial fracture, exhibited gross subcutaneous emphysema in the neck, pneumomediastinum, and pneumoperitoneum. This report aims to contribute to the growing understanding of such cases, potentially leading to the development of a management protocol that may help avoid unnecessary laparotomies in similar scenarios.

Efficacy of splanchnic nerve neurolysis in the management of upper abdominal cancer pain: A systematic review and meta-analysis.

Background and Aims: Neurolytic splanchnic nerve block (NSNB) is practised in intractable abdominal pain secondary to intra-abdominal malignancies. This review evaluated the efficacy of NSNB. Methods: PubMed, Embase, Scopus, and Cochrane databases were searched for articles published from January 2001 to October 2023. Two independent reviewers extracted the data from the included studies. The quality of randomised controlled trials (RCTs) was assessed using the revised Cochrane risk-of-bias tool (RoB 2), and the Newcastle-Ottawa scale was used for cohort studies. Results: Fourteen articles (4 RCTs, 3 non-randomised prospective, and 7 retrospectives) were included. Ten articles were quantitatively assessed and demonstrated significant pain relief at 1 week (standardised mean difference (SMD): 3.46 [2.09, 4.83], P < 0.001, I2 = 95%), 2 weeks (SMD: 4.45 [2.61, 6.29], P < 0.001, I2 = 95%), 4 weeks (SMD: 3.35 [2.23, 4.47], P < 0.001, I2 = 97%), 8 weeks (SMD: 3.7 [2.71, 4.7], P < 0.001, I2 = 86%), 12 weeks (SMD: 4.01 [2.66, 5.36], P < 0.001, I2 = 95%), and 24 weeks (SMD: 2.54 [1.71,3.37], P < 0.001, I2 = 84%). Daily narcotic consumption and quality of life (QOL) significantly improved post neurolysis, but survival rates showed controversial results. Significant heterogeneity was reported, and sub-group analysis revealed a moderate level of variability [I2 = 47.3%] pertaining to study design as a source of heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Pro GDT recommendation for the primary objective was 'high' for the analysis of RCTs and 'very low' evidence quality for observational studies. Only transient minor complications were reported. Conclusion: NSNB appears to be an efficacious technique that provides substantial pain relief, reduces opioid consumption, and ameliorates QOL.

Efficacy of cryoneurolysis in the management of chronic non-cancer pain: A systematic review and meta-analysis.

Background and Aims: Cryoneurolysis, a neuroablative technique, is used in the event of failure of conservative treatment in chronic pain conditions. To date, no systematic review has been published to demonstrate its effectiveness in managing chronic non-cancer pain. Therefore, this review was done to ascertain the efficacy of cryoneurolysis and describe its role in chronic non-cancer pain management. Methods: We searched PubMed, Cochrane, Embase, Scopus, and Google Scholar databases for articles published between January 2011 and September 2021. Two independent reviewers extracted the data from the included studies. Assessment of risk of bias of included randomised controlled trials (RCTs) was done using RevMan 5.4.1 software and Newcastle-Ottawa scale was used for non-randomised studies. Results: Ten studies enroling a total of 425 patients were included in the qualitative analysis. Eight studies were assessed quantitatively. RCTs were found only for cervicogenic headache and knee osteoarthritis management. The rest of the included studies were prospective non-controlled and retrospective studies. A significant pain reduction was seen at seven-day [Standardised Mean Difference (SMD) 1.77 (1.07, 2.46)], P < 0.00001, I2 = 79%), one-month (SMD 3.26 [2.60, 3.92], P < 0.00001, I2 = 45%), three-month (SMD 2.58 [1.46, 3.70], P < 0.00001, I2 = 93%), six-month (SMD 2.38 [0.97, 3.79], P = 0.001, I2 = 86%) follow-ups. Improved disability and no serious complications were noted. Conclusion: Cryoneurolysis appeared to be effective in pain alleviation in refractory painful conditions for up to six months. It is safe and well-tolerated with an excellent safety profile but the quality of evidence is limited by substantial heterogeneity between trials. Therefore, more comparative clinical trials on a larger sample size are needed to provide more concrete evidence.

Immediate Versus Late Flap Coverage for Traumatic Soft Tissue Defects of Lower Extremity: A Comparative Observational Study.

Background The lower extremity trauma in patients often gets operated on late for the wound coverage and is associated with more health costs and other resources. Therefore, this study has been conducted to compare the outcome in terms of flap survival, complication rates, and hospital stay between immediate and late flap coverage of lower extremity traumatic wounds. Methods The comparative analysis of outcome is done in terms of flap survival, complication rates, and hospital stay after immediate and late flap coverage of 25 (n = 25) patients of lower extremity traumatic wounds in each group. The patients were observed, and data obtained were tabulated in a Microsoft Excel spreadsheet. The statistical analysis was done using IBM SPSS (V26.0, IBM Corporation, Armonk, NY, USA) statistical software. The chi-square test was used for descriptive data and the student's unpaired t-test for discrete-continuous data analysis. The p-value of less than 0.05 is considered significant. Results The mean defect size with SD in the immediate flap cover group is 54.5 ± 29.5 cm2, while in the late flap cover group, it is 85 ± 65 cm2 with a significant p-value of 0.0378. The mean flap size with SD in the immediate flap coverage group is 70.5 ± 34.5 cm2, while in the late flap coverage group, it is 117 ± 87.5 cm2, and the difference is statistically significant. The mean hospital stay with SD in the immediate flap coverage group is 7.5 ± 2.5 days. In contrast, in the late flap coverage group, it is 29.5 ± 8.5 days, and the difference is statistically very significant. Conclusion There are equivalent results in patients undergoing immediate and late flap coverage for the traumatic soft tissue defects of the lower extremity. There is a significant decrease in the hospital stay after immediate flap reconstruction, which subsequently reduces both direct and indirect health costs. However, there is a larger size flap requirement in cases of immediate lower extremity wound coverage.

Efficacy of interventional treatment strategies for managing patients with cervicogenic headache: a systematic review.

Cervicogenic headache (CeH) is caused by the disorder of the cervical spine and its anatomical structures. Patients who fail to respond to conservative therapies can undergo interventional treatment. The purpose of this review is to describe the various interventions and compare their relative efficacies. Although a few reviews have been published focusing on individual interventions, reviewing studies on other available treatments and establishing the most efficacious approach is still necessary. We performed a systematic review of studies available on the various interventions for CeH. The PubMed, Embase, and Cochrane databases were searched for literature published between January 2001 and March 2021. Based on the inclusion criteria, 23 articles were included. Two reviewers independently extracted the data from the studies and summarized them in a table. Eleven of twenty-three studies evaluated the effect of radiofrequency ablation (RFA), 5 evaluated occipital nerve blocks, 2 each for facet joint injections and deep cervical plexus blocks, and 1 study each evaluated atlantoaxial (AA) joint injections, cervical epidural injection, and cryoneurolysis. Most of the studies reported pain reduction except 2 studies on RFA. In conclusion, based on the available literature, occipital nerve blocks, cervical facet joint injection, AA joint injection, deep cervical plexus block, cervical epidural injection may be reasonable options in refractory cases of CeH. RFA was found to have favorable long-term outcomes, while better safety has been reported with pulsed therapy. However, our review revealed only limited evidence, and more randomized controlled trials are needed to provide more conclusive evidence.

ECG monitoring in high voltage electric injury patients presenting with normal ECG: Time to revisit practice?

Advanced Trauma Life Support (ATLS) recommends prolonged ECG monitoring of patients with high risk factors post electric injuries, for detecting and treating potentially life threatening arrhythmias. We hereby present our experience of high voltage electric injuries (HVEI) patients with high risk factors, managed at a level 1 Trauma Centre. Seven patients of high voltage electric injuries with significant burns (BSA > 10% of 2nd degree and above) were admitted over a year (Jan 1, 2019 to Dec 31, 2019), age ranging from 11 to 51 (median 25 yrs). Six out of seven patients (85.7%) were males. Mode of injury was recreational in one, workplace related in one and accidental in five (71.4%). Six patients had entry wounds in extremities, and three underwent emergency limb saving surgery (all escharotomies). Three patients underwent eventual amputation of injured extremity. Serum creatine kinase was monitored in all and multisystem involvement was seen in three patients; one patient (referred) required haemodialysis due to renal failure. There was no mortality. In all cases, 24 h continuous ECG monitoring was carried out as per ATLS and ERC (European Resuscitation Council) guidelines. There was no episode of paroxysmal or persistent rhythm disturbance in our patients during in-hospital stay or follow up. Review of pertinent literature suggests similar experiences of other authors. HVEI is a rare injury and most centres have reported on their experience with small number of patients as in our study. Currently, continuous ECG monitoring post HVEI seems to be the safe practice for patients with cardiac co-morbidities. Further studies are required to find other subsets of HVEI patients likely to benefit from ECG monitoring, and the clinical significance of 'delayed arrhythmias' post HVEI.

High voltage electrical injuries: outcomes & 1-year follow-up from a level 1 trauma centre.

BACKGROUND: High voltage (>1000 V) electric injuries (HVEI) are rare, and dreaded due to profound myonecrosis and fatal arrhythmias. Trauma Centres are well equipped for acute and definitive treatment of injuries. Paucity of burn centres in Himalayan belt make trauma centres a prudent choice for management of HVEIs. We share our experience of HVEIs managed at our Level 1 Trauma Centre. METHODS: Study conducted at All India Institute of Medical Sciences, Rishikesh. Patients enrolled from prospectively maintained Trauma Registry. HVEI defined as an electrical shock from a source running current of or more than 1000 Volts. All patients admitted to department of Trauma Surgery with diagnosis of HVEIs, over 17 months (May 2019-Sept 2020) included. Demographics, clinical course, morbidity and management noted. Data is presented descriptively. RESULTS: Prevalence of HVEIs was 0.5% (n=8) among all trauma admissions; all patients were males with median age 25 years. Mode of injury accidental in 6 (75%). Seven patients (87.5%) had entry points in the upper extremity. All patients suffered thermal burns (median BSA 11%). Three patients (37.5%) had secondary fall, no concomitant injury found. Urine myoglobin & creatine kinase measured in all patients. No dysrhythmias detected in index or follow up ECGs. Four patients required emergent escharotomy, four underwent amputation. There was a median of 3 procedures per patient. Fasciotomy (n=6) and grafting (n=3) were commonest operative procedures. Multisystem involvement was seen in 3 patients. In-hospital mortality nil. CONCLUSIONS: HVEIs are rare injuries, predominantly affecting upper extremity of young males. Amputation rates approach 50% despite expeditious surgical management of extremity burn due to progressive myonecrosis. Creatine kinase and urine myoglobin did not correlate with renal failure; ECG monitoring wasn't advantageous in patients with normal index ECG in our study. Modest BSA doesnot rule out visceral damage. Delayed hollow viscus perforation is a possibility in HVEIs involving parietal wall. Vocational loss is common due to high amputation rates of affected extremity, most commonly upper limb. Trauma team is well trained to provide acute, definitive and intensive care, and level I trauma centres with their integrated services are well suited to manage victims of HVEIs in LMICs.

Delayed bowel perforation in electrocution: An unpredictable foe.

Electrocution injuries, particularly high voltage, are uncommon, but can be devastating. Thermal burns, arrhythmias and myonecrosis are commonly known and monitored complications of electrical injuries. Direct thermal trauma to internal viscera is also known and almost all internal organs have been reported to be affected, bowel being the most common. However, bowel perforation occurring in a delayed fashion is one rare, dreaded and erratic complication of electrocution, making it a dangerous pitfall if missed. Alimentary tract perforations can present on a delayed basis in high voltage electrocution injuries; advise for clinical follow up must incorporate this possibility at the time of discharge. Presentation of delayed visceral injuries is subtle & atypical, and post burn immunosuppression may play a part for such presentation. We suggest that all victims of high voltage electrocution with abdominal wall burns receive diagnostic laparoscopy and/or CECT abdomen as part of workup of their injuries. Any non-enhancing segment of bowel on CECT, howsoever small, should be prudently evaluated with laparoscopy.