[Air Embolism of the Left Ventricle due to Pulmonary Stab Wound].

A man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned to undergo hemostatic surgery under general anesthesia. However, shortly after the change in a right lateral decubitus position, he experienced ventricular fibrillation. Hemostasis of the intercostal artery injury, the source of bleeding, and suture of the injured visceral pleura were performed under extracorporeal membrance oxgenation( ECMO). Although sinus rhythm was resumed, when positive pressure ventilation was applied to the left lung for an air leak test, ST elevation on the electrocardiogram and loss of arterial pressure occurred. A transesophageal echo revealed air accumulation in the left ventricle. It was determined that air had entered the damaged pulmonary vein from the injured bronchi due to the stab wound, leading to left ventricular puncture decompression and lower left lower lobectomy. Subsequently, his circulatory status stabilized, and ECMO was weaned off. He recovered without postoperative neurological deficits postoperatively. The mortality rate for chest trauma with systemic air embolism is very high. In cases of deep lung stab wounds, there is a possibility of systemic air embolism, so treatment should consider control of airway and vascular disruption during surgery.

Shared inflammatory glial cell signature after stab wound injury, revealed by spatial, temporal, and cell-type-specific profiling of the murine cerebral cortex.

Traumatic brain injury leads to a highly orchestrated immune- and glial cell response partially responsible for long-lasting disability and the development of secondary neurodegenerative diseases. A holistic understanding of the mechanisms controlling the responses of specific cell types and their crosstalk is required to develop an efficient strategy for better regeneration. Here, we combine spatial and single-cell transcriptomics to chart the transcriptomic signature of the injured male murine cerebral cortex, and identify specific states of different glial cells contributing to this signature. Interestingly, distinct glial cells share a large fraction of injury-regulated genes, including inflammatory programs downstream of the innate immune-associated pathways Cxcr3 and Tlr1/2. Systemic manipulation of these pathways decreases the reactivity state of glial cells associated with poor regeneration. The functional relevance of the discovered shared signature of glial cells highlights the importance of our resource enabling comprehensive analysis of early events after brain injury.

Management of contained penetrating cardiac injury in a patient with prior cardiac surgery.

Penetrating cardiac injuries usually require emergent surgical intervention. Our patient presented to the trauma centre with multiple stab wounds to the neck, chest, epigastric region and abdomen. She arrived haemodynamically stable, and her initial Focused Assessment with Sonography for Trauma exam was negative. Her chest X-ray did not show any evident pneumothorax or haemothorax. Due to her injury pattern, she was taken to the operating room for exploratory laparotomy and neck exploration. Postoperatively, she was taken for CT and found to have a contained cardiac rupture. The injury was contained within previous scar tissue from her prior cardiac surgery. Further evaluation revealed that the injury included a penetrating stab wound to the right ventricle and a traumatic ventricular septal defect (VSD). She subsequently underwent a redo sternotomy with the repair of the penetrating stab wound and the VSD. Cardiology, intensive care, trauma surgery and cardiothoracic surgery coordinated her care from diagnosis, management and recovery. This case highlights the challenges in the management of cardiac injuries and the benefits of a multidisciplinary approach to care for complex cardiac injuries.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Laparotomy for Abdominal Stab Wound With Combined Omental and Organ Evisceration: 10-Year Experience From a Major Trauma Centre in South Africa.

INTRODUCTION: Combined omental and organ evisceration following anterior abdominal stab wound (SW) is uncommon and there is a paucity of literature describing the management and spectrum of injuries encountered at laparotomy. METHODS: A retrospective study was undertaken on all patients who presented with anterior abdominal SW involving combined omental and organ evisceration who underwent laparotomy over a 10-year period from January 2008 to January 2018 at a major trauma centre in South Africa. RESULTS: A total of 61 patients were eligible for inclusion and all underwent laparotomy: 87% male, mean age: 29 years. Ninety-two percent (56/61) had a positive laparotomy whilst 8% (5/61) underwent a negative procedure. Of the 56 positive laparotomies, 91% (51/56) were considered therapeutic and 9% (5/56) were non-therapeutic. In addition to omental evisceration, 59% (36/61) had eviscerated small bowel, 28% (17/61) had eviscerated colon and 13% (8/61) had eviscerated stomach. A total of 92 organ injuries were identified. The most commonly injured organs were small bowel, large bowel and stomach. The overall complication rate was 11%. Twelve percent (7/61) required intensive care unit admission. The mean length of hospital stay was 9 days. The overall mortality rate for all 61 patients was 2%. CONCLUSIONS: The presence of combined omental and organ evisceration following abdominal SW mandates laparotomy. The small bowel, large bowel and stomach were the most commonly injured organs in this setting.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

BACKGROUND: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

A Stab In The Forbidden Territory.

Penetrating heart injuries are associated with higher mortality rates. Coronary lesions caused by penetrating trauma are considered even rarer and universally fatal. We present a case of a fortunate survivor who had complete transection of left anterior descending (LAD) artery with right ventricular (RV) tear after being stabbed by knife, arriving in emergency unit with massively bleeding chest wound. Complex cardiac trauma involving coronaries and cardiac chambers is a challenge to surgeons if patients miraculously reach the hospital alive. This patient had complete transection of LAD artery with penetration into RV cavity, he was successfully managed by timely and prompt surgical intervention by on call team. This case highlights the importance of team dynamics working in harmony during emergency situations, we stress upon conducting routine drills to train surgical residents, perfusionists and operation theatre staff.

Iliopsoas Hematoma and Abscess Formation as a Complication of an Anterior Abdominal Penetrating Injury: a Case Report and Review of Literature.

Background: Abdominal stab wounds are common in clinical practice. However, the development of psoas muscle abscess following such an injury is extremely rare. Moreover, literature surrounding psoas muscle hematoma formation as a consequence of penetrating abdominal injury is scarce. Objective: We report a case of psoas abscess formation following the development of psoas hematoma in a patient who suffered from a penetrating abdominal injury. Case presentation: A 40-year-old Indian male presented to the Emergency department with multiple abdominal cut and stab wounds as a result of physical assault. A computed tomography scan revealed injuries to the ascending colon along with hemoperitoneum and right psoas muscle hematoma. Exploratory laparotomy was performed in which a right hemicolectomy and a right psoas muscle evacuation were successfully achieved along with multiple drainage tubes placed. Six days later, a peritoneal fluid culture tested positive, and a computed tomography scan revealed right psoas muscle collection which was diagnosed as an abscess. Treatment of the abscess included antibiotics and ultrasound-guided drainage. Patient was eventually discharged but was lost to follow-up. Conclusion: The development of iliopsoas abscess and hematoma as a consequence of abdominal penetrating injuries is a rare occurrence. Diagnosis can be made by computed tomography imaging and examination of the drained fluid. Managing a case with both of these rare phenomena can be challenging due to the scarce literature highlighting and comparing the different management modalities.

[Diagnosis and treatment of kidney damage following stab and blunt abdominal injuries]. / Diagnostika i lechenie povrezhdenii pochek pri zakrytykh travmakh i koloto-rezanykh raneniyakh zhivota.

OBJECTIVE: To improve treatment outcomes in victims with kidney damage following blunt and stab abdominal trauma by using of minimally invasive methods of diagnosis and treatment. MATERIAL AND METHODS: About 1.2-3.5% of all victims arrived to the Dzhanelidze St. Petersburg Research Institute for Emergency Care have kidney injuries. We analyzed the results of treatment of 117 patients with isolated and combined blunt and stab abdominal injuries. The retrospective (2014-2017) group included 62 victims, and the prospective (2018-2021) group enrolled 55 patients who were treated according to the new algorithm. This algorithm included non-surgical and minimally invasive management for patients with systolic blood pressure >90 mm Hg after contrast-enhanced CT. Angiography with selective embolization was required for ongoing bleeding. We analyzed incidence of open interventions, organ-sparing procedures, complications, duration of treatment and mortality. Between-group differences were assessed using the χ2 test and Student's test. RESULTS: In both groups, kidney damage in most victims with abdominal trauma was due to road accident and catatrauma. Most patients had combined abdominal injuries, mainly in combination with head and chest lesions. Severity of injuries and clinical condition were similar in both groups. In the retrospective group, there were 9 laparotomies with nephrectomy. Nephrorraphy was performed in 8 cases, kidney vessel suture - in 4 patietns. In the prospective group, nephrectomy was performed in 3 patients with unstable hemodynamics and injuries AAST grade V. Nephrorraphy was performed in 4 victims. In one case, vascular suture was applied for tangential vein damage. All laparoscopies in both groups were diagnostic without nephrectomy. We used non-surgical treatment in 34 patients of the prospective group. One patient underwent angiography and selective embolization of renal artery branches. There were no significant between-group differences in the incidence of infectious and non-infectious complications. Mortality rate was 30.6% (n=19) and 27.3% (n=15) in the retrospective and prospective groups, respectively. CONCLUSION: The proposed algorithm for kidney injury made it possible to reduce the incidence of laparoscopies and laparotomies by 2 times, preserve the damaged kidney in 94.5% of cases and avoid invasive treatment in 62% of victims.

Prospective evaluation of the selective nonoperative management of abdominal stab wounds: When is it safe to discharge?

BACKGROUND: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SWs) remains unclear. The aim of this study was to determine the safe period of observation required before discharge. METHODS: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (July 2018 to May 2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation. RESULTS: During the study period, 256 consecutive patients with an abdominal SW met the study criteria. The mean age was 33 (26-46) years, and 89% were male. Of all patients, 77% had single SW, and 154 (60%) had an anterior abdominal SW (most common site right upper quadrant, 31%). Forty-six (18%) underwent immediate laparotomy because of evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210 patients (82%) were taken for computed tomography scan (n = 208 [99%]) or underwent clinical observation only (n = 2 [<1%]). Of the patients undergoing computed tomography scan, 27 (13%) triggered operative intervention, and 9 (4%) triggered angioembolization. The remaining 174 patients (83%) underwent SNOM. Of these, three patients (2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy. CONCLUSION: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM, and therefore, close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury before discharge of patients with abdominal stab wounds who do not meet the criteria for immediate operative intervention. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

Laminectomy for Penetrating Spinal Cord Injury with Retained Foreign Bodies.

BACKGROUND: Penetrating spinal cord injury (PSCI) with retained foreign bodies (RFB) is rarely observed in clinics and may result in a complete or incomplete neurological deficit. This study was performed to appraise the treatment effect of laminectomy for PSCI with RFB. CASE PRESENTATION: This study presented three patients referred to a tertiary hospital between August 2011 and October 2018 due to PSCI with RFB and receiving laminectomy. The first patient was a 25-year-old female with a butcher's knife piercing the T9 lamina and T10 vertebral body obliquely; the second was a 49-year-old male who suffered a perforating wound of the cervical spinal canal and injury of vertebral artery from foreign glass, while the third was a 60-year-old male with a wooden stick penetrating stomach and terminating in the L1 lamina. The first and second patients immediately underwent laminectomy for debridement and removal of RFB, while the third received two-staged operations to remove the retained stick thoroughly. Unfortunately cases 1 and 3 eventually resulted in total paralysis and case 2 revealed no improvement in myodynamia. Then, Medline/PubMed, Embase and the Cochrane Library were systematically searched, and 23 articles involving 25 additional cases with this kind of injury were included for analysis. CONCLUSIONS: The optimal treatment strategy for penetrating spinal cord injury with retained foreign bodies remains challenging and should be assessed case-by-case. If possible, surgical removal of foreign bodies by laminectomy is preferred immediately to prevent delayed presentation and persistent contamination. Meanwhile, a multidisciplinary team is needed to address concomitant injuries.

A rare case of complicated suicide: Self-immolation and subsequent stab heart injury due to fall into a glass door.

Complicated suicides can be defined as incidents where death is caused by a subsequent trauma rather than the primary injury. Deaths which occur as a complication of the suicidal act are very rare with few reports in the literature. We present the case of a 60-year-old man who was found at his home while still alive. His body was burning and he was lying on his back impaled by shards of glass that had come from a broken glass door. An ambulance was called but the man died before arrival at hospital. The autopsy showed stab heart and lung injuries in thorax and an abdominal stab trauma which resulted in the protrusion of the small intestine. Homicide was excluded and the sequence of events was reconstructed to reveal a complicated suicide intended to result from self-immolation but which resulted in a fall against a glass door which in turn resulted in shards of glass piercing his body and a fatal stab wound to the heart.

TRICUSPID CHORDAL RUPTURE FOLLOWING STAB INJURY: SUCCESSFUL REPAIR WITH THE CLOVER TECHNIQUE.

We report a case of a 32-year-old male patient who sustained an isolated stab injury to the left chest wall. He was initially treated with emergency surgery for right ventricular free wall rupture, with an uneventful postoperative course. During follow-up, the patient complained of exercise intolerance and dyspnea on effort. Transthoracic echocardiography (TTE) demonstrated a previously undiagnosed severe tricuspid regurgitation due to flail of the anterior leaflet and a ruptured chorda. A redo operation was scheduled, and the valve was successfully repaired, with different techniques employed. This case highlights the importance of careful clinical evaluation of victims of chest penetrating trauma and how early diagnosis of hidden valvular lesions might increase the odds of valve repair. It also demonstrates the clover technique as a valuable technique in the correction of traumatic tricuspid regurgitation.

Development of Diaphragmatic Hernia in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

BACKGROUND: This study aimed to investigate the consequences of repairing versus not repairing diaphragmatic injury caused by penetrating left thoracoabdominal stab wounds. METHODS: Diagnostic laparoscopy was performed to evaluate the left diaphragm in patients with penetrating left thoracoabdominal stab wounds who did not have an indication for emergency laparotomy. Patients who did not consent to laparoscopy were discharged without undergoing surgery. Post-discharge radiological images of patients who underwent diaphragmatic repair and radiological images of patients who could not undergo laparoscopy, both during hospitalization and after discharge, were evaluated and compared. RESULTS: Diagnostic laparoscopy was performed on 109 patients. Diaphragmatic injuries were detected and repaired in 32 (29.36%) of these patients. Seventeen patients were lost to follow-up. After a mean follow-up of 57.67 months, none of the remaining 15 patients developed a diaphragmatic hernia. On the other hand, 43 patients refused to undergo diagnostic laparoscopy. Twenty of them were lost from follow-up. The diaphragmatic injury was detected in seven of the remaining 23 patients (30.44%) during initial computed tomography (CT) examinations. In this group, the mean follow-up time was 42.57 months, and delayed diaphragmatic hernia developed in one patient (14.30%). Patients who underwent diaphragmatic repair were compared to patients who did not undergo diagnostic laparoscopy but had diaphragmatic injuries detected on their CT. No statistical differences were detected. CONCLUSIONS: Diaphragmatic injuries caused by penetrating stab wounds can sometimes heal spontaneously. However, diagnostic laparoscopy is still relevant for revealing and repairing possible diaphragmatic injuries.

Stab Wound to the Right Ventricle With Creation of Ventricular Septal Defect Managed With an Endovascular Occlusive Patch.

Penetrating trauma to the cardiac box is associated with high rates of cardiac injury, structural complications, morbidity, and mortality. Early identification and intervention of these injuries is paramount to obtaining good patient outcomes. In this paper, we report a 55-year-old male who sustained a single stab wound to left chest which perforated the right ventricle. The patient also sustained a muscular ventricular septal defect (VSD) which led to a prolonged intensive care unit (ICU) course complicated by late pericardial tamponade. We present successful management of this patient's initial injury along with his ICU course culminating in successful endovascular occlusive patch VSD repair.