The role of leukocytes in predicting whether laparotomy is required in patients with penetrating abdominal stab wound.

BACKGROUND: This study aimed to determine the importance of leukocytes, leukocyte subgroups, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in deciding whether laparotomy is required during observation in patients with penetrating abdominal stab wounds who were followed up because there was no indication for an emergency laparotomy. METHODS: Patients who did not indicate an emergency laparotomy were monitored. After 48 hours from initial hospitalization, patients who did not require laparotomy were discharged nonoperatively. The total leukocytes, leukocyte subsets, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio of patients who underwent laparotomy during the follow-up compared with those who were discharged nonoperatively. The sensitivity and specificity of these laboratory values in predicting the necessity of laparotomy were calculated. RESULTS: In the operated group (n = 71), leukocytes, neutrophils, monocytes, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio examined during observation were significantly higher (P < .001). Eosinophils and lymphocytes were significantly lower (P < .001) than in nonoperated (n = 476). Based on the deviation in the reference ranges of leukocyte and its subgroups, we report the sensitivity and specificity for predicting the necessity of laparotomy as 86% and 72% for leukocyte, 88% and 75% for neutrophil, 92% and 83% for neutrophil-to-lymphocyte ratio, and 72% and 77% for platelet-to-lymphocyte ratio, respectively. In receiver operating characteristic curve analysis, the cut-off value was found to be 4 for neutrophil-to-lymphocyte ratio and 125 for platelet-to-lymphocyte ratio (area under the curve/receiver operating characteristic curve of 0.929 and 0.808, respectively). CONCLUSION: Leukocyte, leukocyte subgroups, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio may be useful to determine if a laparotomy is necessary in patients in whom the necessity of laparotomy is undetermined owing to unclear examination findings.

Bacillus cereus bacteremia in a patient with an abdominal stab wound / Bacteriemia por Bacillus cereus en paciente con herida de arma blanca abdominal

Abstract Bacillus cereus is a gram positive microorganism commonly involved in gastrointestinal infection but capable of causing severe infections and bacteremia. We describe here a case of bacteremia caused by B. cereus in a previously healthy young woman admitted to the intensive care unit following emergency surgery due to a penetrating abdominal stab wound and subsequent hepatic lesion. She developed fever during admission and cultures were taken. B. cereus was isolated in blood and hepatic fluid collection cultures. Treatment was adjusted according to the isolate, with good clinical results. It is important to highlight the pathogenic potential of this microorganism and not underestimate it as a contaminant when it is isolated from blood samples.

Resumen Bacillus cereus es un microorganismo gram positivo comúnmente involucrado en infecciones gastrointestinales, pero capaz de causar infecciones graves y bacteriemia. Presentamos un caso de bacteriemia por B. cereus en una mujer joven previamente sana que ingresa en la unidad de cuidados intensivos luego de una cirugía de emergencia, debido a una herida abdominal por arma blanca con lesión hepática. La paciente desarrolla fiebre durante la internación, por lo que se toman cultivos. Se aísla B. cereus en hemocultivos y material de colección hepática. Se ajusta el tratamiento según los hallazgos, con buena evolución clínica. Esta comunicación ilustra una fuente poco común de bacteriemia por B. cereus. Asimismo, destaca el potencial patogénico de este microorganismo, cuyo hallazgo en muestras de sangre no siempre debe conducir a su rápida desjerarquización como contaminante.

Bacillus cereus bacteremia in a patient with an abdominal stab wound.

Bacillus cereus is a gram positive microorganism commonly involved in gastrointestinal infection but capable of causing severe infections and bacteremia. We describe here a case of bacteremia caused by B. cereus in a previously healthy young woman admitted to the intensive care unit following emergency surgery due to a penetrating abdominal stab wound and subsequent hepatic lesion. She developed fever during admission and cultures were taken. B. cereus was isolated in blood and hepatic fluid collection cultures. Treatment was adjusted according to the isolate, with good clinical results. It is important to highlight the pathogenic potential of this microorganism and not underestimate it as a contaminant when it is isolated from blood samples.

[CORRECTION OF HEMOSTASIS DISORDER IN HEMORRHAGIC SHOCK].

It is a clinical case of successful correction of hemostasis disorder in hemorrhagic shock. This case demonstrates the need to perform advanced tests that assess hemostatic system in patients with ongoing bleeding. Using of thromboelastography helped us to make a comprehensive assessment of hemostatic system that allowed to detect the point of application of drugs and substitution therapy. Coagulation disorder was treated by intravenous injection of Ca2+. In this case the cause of hypocalcemia was combination offactors such as electrolytes losing during massive bleeding and progressing metabolic acidosis. Therefore, monitoring the level of ionized calcium is especially important in patients undergoing massive blood loss and receiving large doses of donor blood components.

Massive pulmonary embolism as a rare complication of a stab in the inguinal region in a HIV-positive patient: a case report.

OBJECTIVE: Venous thromboembolism (VTE) is a severe preventable disease; HIV-infection represents a prothrombotic condition, because of specific factors due to the virus itself, the host response and the antiretroviral therapy. Our aim is to raise awareness of thromboembolic risk when dealing with HIV-positive patients presenting to the Emergency Department for treatment of injuries, even though small. CASE REPORT: We present a case of a 33-year-old woman suffering from HIV-infection who presented to the Emergency Department with two small stab wounds. Laboratory tests and radiologic examinations were normal. About 8 hours after admission the patient developed a syncopal attack: a CT scan performed after hemodynamic stabilization revealed a massive pulmonary embolism (PE); the patient was then transferred to the Intensive Care Unit and treated with systemic thrombolysis. CONCLUSIONS: This case confirms that HIV-positive patients carry a higher risk for VTE and PE compared to general population, similarly to patients suffering from cancer: emergency physicians must be aware even in case of minor wounds.

Predictive value of liver transaminases levels in abdominal trauma.

INTRODUCTION: We aimed to evaluate whether hepatic transaminase levels could predict the presence and severity of liver injury following abdominal trauma. METHODS: We performed a retrospective analysis of 75 surgically treated patients and 21 non-surgically treated patients with liver injury who were managed between 2004 and 2012. We retrieved demographic, laboratory, radiologic, and intraoperative data, as well as surgical procedures and the outcome from the patients' medical records. We compared the findings between patients divided into 2 groups according to the severity of liver injury: group 1, including patients with Grade 1 or 2 liver injuries; and group 2, including patients with grade 3 to 5 liver injury. RESULTS: There were 87 (90.6%) males and 9 (9.4%) females. The mean age was 34 years (range, 17-90 years). The overall mortality rate was 14.6% (n = 14). The injury was blunt in 83 patients (86.5%) and penetrating in 13 patients (13.5%). There were multiple traumas in 60 patients (62.5%). Overall, 43 patients (44.8%) had a total of 61 coexisting intraabdominal injuries. The circulating aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase (LDH) levels were significantly higher in group 2 than in group 1. CONCLUSIONS: In patients with abdominal trauma, abnormal hepatic transaminase and LDH levels are associated with liver injury. Alanine aminotransferase ≤76 U/L, aspartate aminotransferase <130 U/L, and LDH ≤410 U/L are predictive of low-grade liver injury, and patients with serum liver levels below these levels can be managed conservatively.

The effects of maggot secretions on the inflammatory cytokines in serum of traumatic rats.

The objective of this study was to analyse the changes of inflammatory cytokines level in traumatic rat serum after maggot secretions intervention. Acute traumatic rats were randomly divided into three groups that included maggot secretions group, negative group, and the control group. TNF-α, IL-6, SOD, LPO levels were measured by radioimmunoassay. The experimental results showed that TNF-α, IL-6, and SOD levels in the model group were significantly increased; LPO level was decreased and showed significant differences. Thus, the content of inflammatory cytokines in acute skin wounds could be reduced by maggot secretions, which play a role in enhancing wound healing.

[Preoperative leukocytosis as a predictor of intrabdominal injury in penetrating abdominal trauma]. / Leucocitosis prequirúrgica como factor predictivo de lesión a órgano intrabdominal en trauma penetrante abdominal.

BACKGROUND: in Mexico, the management of abdominal penetrating trauma doesn't follow the algorithms of Trauma Center level I, because of our limitations, and laparotomies are inevitable in this context. Is possible use some grade of leukocytosis suspect in-trabdominal lesion? METHODS: study retrospective, descriptive and analytic that inclu-ded patients with abdominal penetrating trauma that suffered exploratory laparotomy. We excluded patients' whit severe damage to soft tissues in extremities, thoracic affection, fractures, or da-mage in nervous system. We divided the patients into 2 groups: group I (therapeutic laparotomy) and group II (non-therapeutic laparotomy). Dependent variables were; age, gender, type of injury, number of lesions, peripheral lesions, time between injury and, from a laboaratory blood sample, leukocytosis mean, percentage of neutrophils, leukocytosis ≥ 12,500 /mm(3), and hemoperitoneum. We compared variables between two groups and use Pearson's χ(2) test and T-Student, and percentages as summary of measures. RESULTS: we included 231 patients, group I with 159 patients and group II with 72 patients. Leukocytosis global was 13.2 mil/mm(3) and neutrophil range of 70.3%. 26% of patients did not have leukocytosis at arrival and evaluation, however they were laparotomized because of present peritoneal irritation. Leukocytosis ≥ 12.5 mil/mm(3) was statistically significant in patients with intrabdominal lesions (74.2% vs 27.7%, p < 0.001). CONCLUSIONS: leukocytosis ≥ 12.5 mil/mm(3) could be an early serum marker abdominal penetrating trauma.

Case report: intraoperative management of extreme hemodilution in a patient with a severed axillary artery.

We present a case of extreme hemodilution in which appropriately crossmatched blood was not available. A 53-year-old man was admitted to our hospital because of hemorrhagic shock due to multiple stab wounds. His blood type was B, Rh negative, and his intravascular fluid volume was maintained with balanced salt solution and plasma substitutes, i.e., hydroxyethyl starch. His hemoglobin reached a nadir of 0.7 g/dL and hematocrit 2.2% before being transfused. No evidence of cardiac ischemia was noted and he was discharged in good condition. Extreme hemodilution can be successfully managed by maintaining a normal blood volume, 100% oxygen, and the use of plasma substitutes.

Postmortem serum erythropoietin level as a marker of survival time in injury deaths.

Circulating erythropoietin (EPO) is mainly derived from the kidneys, and the serum concentration is rapidly increased in response to anemia and hypoxia. The present study investigated postmortem serum EPO levels in injury death cases (n=185, postmortem time<48 h, survival time <7 days: sharp instrument injury, n=44 and blunt injury, n=141) with regard to survival time, compared with C-reactive protein (CRP) as a marker of inflammation. Serum levels of both markers were independent of postmortem time. A survival time-dependent increase in serum EPO up to about 100 mU/ml was seen within 6h of sharp instrument injury to the heart or a proximal major vessel (thoracic aorta or subclavian/carotid artery) and blunt injury with massive hemorrhages, showing high correlations (r=0.957 and r=0.822, respectively, P<0.0001), whereas the increase was insignificant (P>0.05) for sharp instrument injury to a peripheral vessel or lungs/abdominal viscera and blunt injury with minor hemorrhages over the same survival period. A further increase (>100 mU/ml) was often detected in cases of death about 24h after blunt injury, irrespective of the type of injury. In contrast, a gradual increase in serum CRP level was seen about 12-24h after blunt injury. These findings suggest that serum EPO can be a marker for investigating survival time within 6h of major injury involving acute massive hemorrhaging.

von Willebrand factor in cadaveric urine for forensic investigation.

Preliminary experimental study of urinary von Willebrand factor (VWF) concentration was undertaken to evaluate the utility of this parameter in forensic investigations. ELISA was used to measure VWF concentration. Correlations of urinary VWF with cause of death and postmortem interval (PMI) were ascertained. As PMI advanced, urinary VWF increased but plasma VWF did not. Cause of death was not significantly correlated with VWF. This study indicated the possibility that urinalysis would be helpful to estimate PMI.

Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma?

BACKGROUND: Controversy exists regarding the interpretation of diagnostic peritoneal lavage results. This is especially true in the evaluation of patients sustaining penetrating trauma, specifically stab wounds to the lower chest and abdomen. Ideally one wants to avoid missed injuries and minimize unnecessary operations. METHODS: This is a retrospective review of 195 patients sustaining stab wounds to the anterior lower chest and abdomen at Parkland Memorial Hospital between 1993 and 2005, looking at missed injuries and false positive rates using red cell counts of 100,000, 10,000, and the standard criteria for blunt trauma including >500 white blood cells (WBCs), amylase, and/or bile. RESULTS: The first analysis used >100,000 red blood cells (RBCs)/mm3 as a positive value. The false positive rate was 12.2%. The second analysis used >10,000 RBCs/mm3 as a positive value with a false positive rate of 44%. When considering the entire study population (195 patients), the false positive rate increased when using the lower number (>10,000) from 2.5% to 15.8% (p < 0.001). There were no missed injuries when using >100,000 red cells and/or >500 white cells, the presence of bile or amylase. CONCLUSION: Decreasing the red blood cell count from >100,000 to >10,000 as the criteria for operating on patients with stab wounds to the anterior lower chest and/or abdomen will significantly increase the number of nontherapeutic procedures. Based on this study, >100,000 RBCs/mm3 appears to be a valid and safe number to use when evaluating these patients, particularly when used with other positive criteria such as increased white cells, bile, and amylase.

Are resuscitation and operation justified in injured patients with extreme base deficits (less than -20)?

BACKGROUND: This study assessed the outcome of injured patients in shock with an admission base deficit of -20 or less (approximate pH <7.0) at a level 1 trauma center. METHODS: A retrospective review was made of the trauma registry, supplemented by chart review, of all trauma patients admitted with a base deficit -20 or less from 1995 to 2002. Data collected included mechanism of injury, base deficit, Injury Severity Score(ISS), operative procedures, and outcome. Data are presented as mean +/- SD. RESULTS: Over the study period, 110 trauma patients (88% male; 31 +/- 13 years; 34% blunt trauma; ISS 26 +/- 15) were admitted with base deficit of -20 or less. Overall survival was 38%, with the majority of deaths occurring within hours of admission. CONCLUSIONS: An admission base deficit of -20 or less is associated with high mortality in patients with gunshot wounds (64%) or blunt trauma (70%). The majority of patients who die will do so within hours of admission. Beyond 24 hours, the survival rates of 73% for patients with blunt trauma, 79% for those with gunshot wounds, and 90% for those with stab wounds justify continuing resuscitation and reoperations.

[Chronology of a homicide and an attempted suicide by DNA analysis of selected blood stains on the weapon (knife)]]. / Untersuchungen zur Chronologie eines Tötungsdeliktes und eines Suizidversuches durch DNA-Analyse von ausgewählten Blutspuren am Tatwerkzeug (Messer).

A five-year-old boy was fatally injured by a stab and a cut to the throat. The suspected offender, an acquaintance of the victim's mother, stated that he had been disturbed by the boy while attempting suicide and had therefore killed the boy. The suspect showed superficial cuts on both wrists and three shallow stabs on the right-hand side of the abdomen. The purpose of the forensic investigations was to answer the question if the suspect's statement could be confirmed or if the attempted suicide took place after killing the boy. The blood-smeared blade of the knife was divided into different sectors with the cutting edge and the tip of the blade being examined separately from the sides. The blood traces from the different blade sectors were then typed in 12 different DNA regions by PCR (polymerase-chain-reaction). It could be demonstrated that the strong blood traces on the sides of the blade originated from the victim alone, whereas in the area of the edge and the tip of the blade the amount of the victim's blood was negligible compared with that of the suspected offender. The explanation for this finding is that in the areas of the edge and the tip of the knife the blood of the victim must have been replaced by the blood of the suspected perpetrator, which means that the suicidal injuries were the last to be caused by the knife.

Vagaries of the lavage white blood cell count in evaluating abdominal stab wounds.

BACKGROUND: The clinical value of an elevated white blood cell (WBC) count on a diagnostic peritoneal lavage (DPL) performed in an asymptomatic patient with a penetrating abdominal stab wound is controversial. METHODS: We performed a comprehensive analysis of asymptomatic patients (no signs of peritonitis) with stab wounds who underwent an exploratory laparotomy based solely on a WBC count > 500/mm3 in the effluent of an open DPL. RESULTS: Twenty-eight patients, 25 with injury to the gastrointestinal (GI) tract and 3 with injury to the liver, obtained true-positive results from DPL. Their mean WBC count in lavage effluent obtained at a mean of 7.6 hours after the stab wound was 3,380/mm3 and their mean serum WBC count, obtained at the same time, was 12,324/mm3. Fifteen patients had false-positive results from DPL. They were lavaged at a mean of 7.2 hours after the stab wound, and had a mean lavage WBC count of 1,228/mm3 and a mean serum WBC count of 9,084/mm3. CONCLUSIONS: Patients lavaged at a mean 6 to 7 hours after an abdominal stab wound will have a significant incidence of false-positive studies based on an elevated WBC count alone. Lavage WBC counts > 3,000/mm3, particularly when associated with a serum WBC count > 11,000, are likely to be true positives and to indicate injury to the GI tract.

[The use of trace deposits for establishing the weapon of an injury]. / Ispol'zovanie sledov-nalozhenii dlia ustanovleniia orudiia travmy.

The author analyzes the value of traces detectable on stabbing and cutting instruments (traces of blood, isolated cells of the injured organs and tissues of human body, trace particles of textile fabrics) for the identification of the instrument of injury. A comprehensive assessment of the fact of detection of material traces and of the specific features of injuries of victim's body and clothes helps in some cases identify the instrument of injury.