Antiphospholipid syndrome with renal and splenic infarction after blunt trauma:A case report

BACKGROUND In trauma patients,bleeding is an immediate major concern.At the same time,there are few cases of acute vascular occlusion after blunt trauma,and it is unclear what assessment and diagnosis should be considered for these cases.Herein,we describe a patient diagnosed with antiphospholipid syndrome after a hypercoagulable workup for acute renal and splenic vascular occlusion due to blunt trauma.CASE SUMMARY A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago.He had no medical history.Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney and occlusion of branches of the splenic artery with infarction of the central portion of the spleen.Attempted revascularization of the left renal artery occlusion through percutaneous transluminal angioplasty failed due to difficulty in passing the wire through the total occlusion.Considering the presence of acute multivascular occlusions in a young man with low cardiovascular risk,additional laboratory tests were performed to evaluate hypercoagulability.The results suggested a high possibility of antiphospholipid syndrome.Treatment with a subcutaneous injection of enoxaparin was started and changed to oral warfarin after two weeks.The diagnosis was confirmed,and he continued to visit the rheumatology outpatient clinic while taking warfarin.CONCLUSION A hypercoagulable workup can be considered in trauma patients with acute multivascular occlusion,especially in young patients with low cardiovascular risk.

Diagnosis and treatment of 34 cases of blunt duodenal injuries

Objective:To summarize the experience on diagnosis and treatment of blunt duodenal injuries,and thus to improve the therapeutic skills. Methods:Clinical data of 34 cases of blunt duodenal injuries admitted to our hospital from 1990 to 2006 were retrospectively analyzed. Results:Among them,28 cases were cured,20 cases presented with complications,and 6 cases died.The causes of death were:duodenal or pancreatic fistula in 2 cases, intra-and retroperitoneal infection complicating septicopyemia in 2,disseminated intravascular coagulation in 1 and multiple organ failure in 1. Conclusions:Misdiagnosis and missed diagnosis predispose to happen for blunt duodenal injuries.Early recognition and surgical intervention are critical to a successful rescue.

Diagnostic accuracy of CT scan in abdominal blunt trauma

Objective： To evaluate the sensitivity and specificity of CT scan findings in patients with blunt abdominal trauma admitted to the university hospital. Methods： All the patients with blunt abdominal trauma admitted at a tertiary teaching trauma center in Iran between 2005 and 2007 were enrolled in this study. In the absence of any clinical manifestations, the patients underwent a diagnostic CT scan. Laparatomy was performed in those with positive CT results. Others were observed for 48 hours and discharged in case no problem was reported; otherwise they underwent laparatomy. Information on patients＇ demographic data, mechanism of trauma, indication for CT scan, CT scan findings, results of laparotomy were gathered. The sensitivity, specificity and accuracy of the CT-scan images in regard with the organ injured were calculated. The sensitivity, specificity and accuracy of the CT scan were calculated in each case. Results： CT scan had the highest sensitivity for detecting the injuries to liver （100%） and spleen （86.6%）. The specificity of the method for detecting retroperitoneal hematoma （100%） and injuries to kidney （93.5%） was higher than other organs. The accuracy of CT images to detect the injuries to spleen, liver, kidney and retroperitoneal hematoma was reported to be 96.1%, 94.4%, 91.6% and 91.6% respectively. Conclusion： The findings of the present study reveal that CT scan could be considered as a good choice, especially for patients with blunt abdominal trauma in teaching hospitals where the radiologic academic staff is not present in the hospital in the night shifts.

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

Objective: To explore a way of guiding diagnosis and treatment of blunt and penetrating diaphragm injuries. Methods: According to injury violence, 46 chest trauma patients with diaphragm rupture were divided into two groups: a blunt injury group and a penetrating injury group. The injury condition and trauma scores between the two groups were compared and analyzed. Results: The incidence of blunt diaphragm injuries was lower than that of penetrating injuries ( 1.78 % vs 8.53 %, P< 0.05 ). In the blunt injury group most patients had multiple injuries. Penetrating injuries developed more quickly than blunt injuries, and resulted in hemorrhagic shock in the early period. Trauma scores showed that there was no significant difference in the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and thoracic Abbreviated Injury Scale (AIS) between the two groups (P> 0.05 ), but the blunt injury group had lower Glasgow Coma Scale (GCS) and abdominal AIS than the penetrating group (P< 0.05 ). Conclusions: Blunt and penetrating diaphragm injuries have different clinical characteristics. So they should be dealt with differently to reduce the incidence of complication and improve prognosis.

Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience

Purpose:To analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair(TEVAR)in patients with traumatic blunt aortic injury in our single-center.Methods:From January 2014 to December 2018,a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center.Their clinical data such as demographics,operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software.Continuous variables were expressed as mean and standard deviation or median and interquartile range.Categorical variables are expressed as the numbers and percentages of patients.Results:The median age of the patients was 37 years,and 76(85.4%)were males.All the patients were involved in violent accidents and combined with associated injuries.Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR,with a 100%technique success.The mean time interval from admission to operating room was(90.1±18.7)min,and the mean procedure time was(54.6±11.9)min.Eighty(92.0%)patients were operated on under local anesthesia,while other 7(8.0%)patients were under general anesthesia.Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels.A total of 98 aortic covered stent grafts were deployed,of which 11 patients used two stent grafts(all in dissection cases).The length of the stent was(177.5±24.6)mm.The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was(24.9±2.4)mm,the proximal diameter of the covered stent was(30.5±2.6)mm,and the oversize rate of proximal site was(22.7±4.0)%.The proximal landing zone length was(14.1±5.5)mm.The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients.No blood flow reconstruction was performed.The overall aortic-related mortality was 2.25%(2/89).Among 87 patients,the median follow-up time was 24 months.Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm,hematoma or endoleak.One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion.Neither late death,nor neurological or other complications occurred.Conclusion:Emergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries.Long-term results remain to be further followed.

Evaluating clinical abdominal scoring system in predicting the necessity of laparotomy in blunt abdominal trauma

Objectives： Trauma is among the leading causes of death. Medical management of blunt abdominal trauma （BAT） relies on judging patients for whom laparotomy is mandatory. This study aimed to determine BAT patients＇ signs, as well as paraclinical data, and to clarify the accuracy, sensitivity, specificity, positive and negative predictive value of clinical abdominal scoring system （CASS）, a new scoring system based on clinical signs, in predicting whether a BAT patient needs laparotomy or not. Methods： Totally 400 patients suspected of BAT that arrived at the emergency department of two university hospitals in Tehran from March 20, 2007 to March 19, 2009 were included in this study. They were evaluated for age, sex, type of trauma, systolic blood pressure, Glasgow coma scale （GCS）, pulse rate, time of presentation after trauma, abdomial clinical findings, respiratory rate, temperature, hemoglobin （Hb） concentration, focused abdominal sonography in trauma （FAST） and CASS. Results： Our measurements showed that CASS had an accuracy of 94%, sensitivity of 100%, specificity of 88%, positive predictive value of 90% and negative predictive value of 100% in determining the necessity of laparotomy in BAT patients. Moreover, in our analysis, systolic blood pressure, GCS, pulse rate, Hb concentration, time of presentation after trauma, abdominal clinical findings and FAST were also shown to be helpful in confirming the need for laparotomy （P〈0.05）. Conclusion： CASS is a promising scoring system in rapid detection of the need for laparotomy as well as in minimizing auxiliary expense for further evaluation in BAT patients, thus to promote the cost-benefit ratio and accuracy of diagnosis.

Establishment of a blunt impact-induced brain injury model in rabbits

Objective： To establish an animal model to replicate the blunt impact brain injury in forensic medicine. Methods： Twenty-four New Zealand white rabbits were randomly divided into control group （n=4）, minor injury group （n：10） and severe injury group （n=10）. Based on the BIM- II Horizontal Bio-impact Machine, self-designed iron bar was used to produce blunt brain injury. Two rabbits from each injury group were randomly selected to monitor the change ofintracranial pressure （ICP） during the impact- ing process by pressure microsensors. Six hours after injury, all the rabbits were dissected to observe the injury mor- phology and underwent routine pathological examination. Results： Varying degrees of nervous system positive signs were observed in all the injured rabbits. Within 6 hours, the mortality rate was 1/10 in the minor injury group and 6/10 in the severe injury group. Morphological changes con-sisted of different levels of scalp hematoma, skull fracture, epidural hematoma, subdural hematoma, subarachnoid hemo- rrhage and brain injury. At the moment of hitting, the ICP was greater in severe injury group than in mild injury group; and within the same group, the impact side showed positive pressure while the opposite side showed negative pressure. Conclusions： Under the rigidly-controlled experimental condition, this animal model has a good reproducibility and stable results. Meanwhile, it is able to simulate the morphology of iron strike-induced injury, thus can be used to study the mechanism of blunt head injury in forensic medicine.

Hemiparesis in carotid cavernous fistulas (CCFs): a case report and review of the literature

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous anastamoses between the carotid artery and the cavernous sinus. These fistulas may be classified by cause (spontaneous or traumatic), flow velocity (high or low), or pathogenesis (direct or indirect). The most commonly adopted classification is that described by Barrow based on arterial supply. Traumatic CCFs are almost always direct shunts between the internal carotid artery (ICA) and the cavernous sinus. General features of CCFs, which may be apparent with any lesion, including bruit, headache, loss of vision, altered mental status and neurological deficits. Some fistulae may present primarily with hemorrhage before any evaluation can be performed. However, hemiparesis has been rarely observed. Only a literature review of Murata et al reported a case of hemiparesis caused by posttraumatic CCF, in which the fistula resulted in venous hypertension and subsequent brainstem congestion. While in our case, cerebral infarction was caused by total steal of the blood flow. The patient recovered after occlusion of the fistula with a detachable balloon.

Extraperitoneal Rectal Laceration Secondary to Blunt Trauma： Successful Transanal Endoscopic Repair with Hemoclips

Rectal injuries are caused by a variety of causes, such as stab wounds, gunshot injuries, blunt trauma, and foreign bodies. In particular, extraperitoneal rectal injury secondary to blunt trauma is very rare in the civilian setting and usually seen in association with comminuted fractures of the pelvis or sacrum and evidence of intraperitoneal injury.[1] The management of extraperitoneal rectal injury is treated either surgically or conservatively depending on the level and extent of the injury.[2] Currently, management of less severe extraperitoneal rectal injury is not standardized, but primary closure of the wound should be performed whenever possible. Therefore, we present a patient with a laceration of the midrectum secondary to blunt trauma who was successfully treated with endoscopic hemoclipping.