Commentary: the role of sonography in the initial evaluation of children after blunt abdominal trauma.
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Abdominal Injuries↗
Biomedical subjects
S Stylianos
Publications and source records attributed to S Stylianos.
Incarceration of inguinal hernia in infants prior to elective repair.
The low morbidity and good results of elective herniorrhaphy in children are adversely affected by incarceration. Since incarceration is a potentially avoidable complication, we reviewed 908 consecutive cases to determine its incidence and consequences in children awaiting elective operation for an inguinal hernia. Eighty-five of the 908 children presented with an incarcerated hernia. Thirty of these 85 patients (35%) were known to have an inguinal hernia prior to incarceration, and 25 of the 30 were awaiting elective hernia repair. The median time from surgical office visit to planned operation was 22 days, but the mean interval from office visit to incarceration was 8 days. Eighty-five percent of the children with incarcerated hernias were infants under 1 year of age. Seventy-one of the 85 patients with an incarcerated hernia (84%) had successful manual reduction. They were all admitted and had a mean hospital stay of 2.5 days. Emergency operation after unsuccessful attempts at reduction was required in the other 14 children, increasing the average length of stay to a mean of 4.0 days. Significant complications, including infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia, occurred in 26 of the 85 children (31%). We conclude that incarceration is a preventable problem. Even patients scheduled for hernia repair are at risk and the operation should be performed soon after the diagnosis is made. Infants are the highest priority group, since 35% of children less than 12 months of age experienced incarceration while awaiting elective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Female↗
Pediatric trauma. Prevention strategies.
Injury is the most important threat to the health of children in the United States and the leading cause of death after the first year of life. Injuries must be viewed as diseases that can be prevented by using principles of epidemiology, engineering, biomechanics, and health education. Effective preventative strategies coupled with improvements in access and delivery of pediatric trauma care can reduce the tremendous toll on children.
Accident Prevention↗
Experimental volume replacement through lower extremity veins.
Hypovolemic shock was produced in anesthetized pigs by removal of 40% of blood volume over 10 minutes. Following blood loss, the inferior vena cava (IVC) was occluded below the renal veins to simulate the hemodynamics of emergency surgical treatment. Control animals were not treated. Experimental animals received intravenous lactated Ringer's solution equal to three times the blood loss given through catheters either in the IVC or the superior vena cava (SVC) to determine if lower extremity access would be efficacious in this model. To define the path taken by the resuscitation fluids, an additional group of animals received technetium-99m-labelled crystalloid through lower extremity catheters with continuous recording of isotope counts in the IVC and right atrium. The treated animals in all experimental groups had significant improvements in mean arterial pressure, cardiac output, and pH compared with controls. There was no significant difference in hemodynamic response in animals receiving volume replacement through the IVC compared with the SVC. When fluid was infused below a clamped IVC, the arrival of isotope in the right atrium was delayed only 1.5 seconds. We conclude that in a model simulating emergency control of potentially lethal hemorrhage, the beneficial effects of fluid resuscitation are unrelated to the site of venous access. Lower extremity veins provide a valuable site for volume replacement even with IVC occlusion. These findings should have direct application to resuscitation and surgical care of seriously injured patients.
Animals↗
Occult diaphragm injuries at celiotomy for left chest stab wounds.
No dependable test exists for diagnosis of diaphragmatic injury in asymptomatic patients with thoraco-abdominal stab wounds. Forty-one consecutive patients with anterior stab wounds of the lower left chest were treated in a 30-month period. In the 21 patients seen during the first 15 months, operations were reserved for those with peritoneal signs or continuing blood loss. Ten of these 21 patients (48%) required celiotomy; 2 patients (10%) had isolated diaphragm injuries and there was one negative celiotomy. Of the eleven patients who were not explored, 2 (18%) returned within 18 months after injury with an incarcerated diaphragmatic hernia. During the subsequent 15 months, the next 20 patients were managed by routine celiotomy in a prospective study. The admission systolic blood pressure and incidence of pneumothorax, celiotomy, diaphragm injury, isolated diaphragm injury, and unnecessary celiotomy in these two groups were compared. Ten patients in the prospective group (50%) were found to have isolated diaphragm injuries (P less than 0.005) and 7 (35%) had negative celiotomies (P less than 0.02). The true incidence of occult diaphragm injuries may be underestimated. In the prospectively studied group, the policy of routine celiotomy for anterior stab wounds of the lower left chest resulted in recognition and repair of a fivefold greater number of isolated diaphragm injuries. In the absence of a reliable, noninvasive test to diagnose penetration of the diaphragm, celiotomy should be considered in light of the risks of late strangulation.
Adolescent↗
Sutureless hemisplenectomy.
Splenic salvage following blunt injury can fail when parenchymal bleeding is uncontrollable. To define the usefulness of an argon beam coagulator for hemostasis, we used the instrument in a laboratory trial of partial splenic resection. New Zealand white rabbits, weighing 4 to 5 kg, had sharp excision of the lower half of the spleen. No sutures were used to control hemorrhage from the cut splenic surface or the hilar vessels. Hemostasis was achieved with 2 to 4 seconds of electrocoagulation delivered by a beam of argon gas. All animals survived the procedure and were in good health when killed between the fourth and sixth week following the procedure. At necropsy, the spleen was viable in all animals with no abscess or hematoma. Minimal adhesions from the treated splenic surface to the omentum were found. The scar at the cut surface was 1 mm in depth, and the histology of the remainder of the spleen was normal. In this simulated splenic injury model, argon beam coagulation was uniformly successful in achieving hemostasis. Minimal tissue destruction and lack of infection were noted. The argon beam coagulator may be useful in patients with severe splenic injuries and other situations requiring partial splenectomy.
Animals↗
Femorofemoral artery bypass for blunt iliac artery occlusion in a child.
Vascular injuries from blunt trauma are rare in children. This report concerns traumatic occlusion of the common iliac artery with limb-threatening ischemia in a 6-year-old boy sustained while wearing a lap belt. Associated injuries included fracture of the third lumbar vertebra, perforation of the sigmoid colon, and disruption of the anterior abdominal wall musculature. Because of fecal contamination from the colon perforation, revascularization using a subcutaneous prosthetic femorofemoral artery bypass was performed and proved successful in limb salvage. As improved prosthetic vascular conduits of smaller caliber are developed, applications in small children with vascular injuries may increase.
Accidents, Traffic↗
Experimental hemorrhage and blunt trauma do not increase circulating tumor necrosis factor.
Tumor necrosis factor (TNF) is a potent cytokine mediator of the shock states associated with sepsis and burn injury. This experimental study was done to determine whether circulating TNF plays a major role in the vasomotor collapse seen following experimental hemorrhage and blunt injury. Twenty anesthetized pigs were divided into two groups. Ten animals were bled 60% of their calculated blood volume in 15 minutes. Animals in Group IA (n = 5) had no treatment, and Group IB animals (n = 5) were given twice the shed volume as crystalloid 30 minutes after hemorrhage. The other animals, groups IIa and IIb (n = 5 each), were first subjected to a blunt injury to the thigh sufficient to cause a midshaft femur fracture, then bled and similarly treated. In both groups, mean arterial pressure (MAP), cardiac output (CO), and serum TNF activity by L929 bioassay were measured at 15-minute intervals for 120 minutes after hemorrhage or hemorrhage and blunt injury. An additional three animals were infused with 4 x 10(8)/kg heat-killed E. coli to validate the TNF assay. All bled animals sustained a fall in MAP and CO to a mean of 33% of baseline values, with or without fracture. Group IB and IIB animals responded to fluid resuscitation by restoration of MAP and CO to 85%-97% of the baseline values. Tumor necrosis factor was not detectable before injury and remained undetectable in all these animals during the 120 minutes of the experiment despite hemorrhage alone or combined hemorrhage and blunt trauma, with or without fluid resuscitation. The test animals receiving the E. coli responded with markedly elevated TNF levels, which peaked at 90 minutes after injection.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Traumatic renal avulsion into the chest: case report.
This is a case report of a patient who survived blunt renal avulsion and herniation of the kidney through a ruptured diaphragm. Symptoms were mild considering the severity of injury. Prompt diagnosis of this unusual combination of injuries was aided by contrast-enhanced computed tomography (CT).
Accidents, Traffic↗
Pediatric blunt liver injury and coagulopathy managed with packs and a silo: case report.
Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.
Accidents, Traffic↗
Seatbelt use and patterns of central nervous system injury in children.
Family protocol often dictates that children too old for car seats occupy the rear seat when travelling with adults. In most vehicles, the only available rear seat restraint is a lap belt. Our recent experience with a group of children who were rear seat passengers at the time of a motor vehicle accident suggests that patterns of injury may be influenced by use of lap belts.
Abdominal Muscles↗
Influence of monoclonal IgM cold agglutinins on adhesiveness, phagocytosis, and bactericidal activity on human granulocytes and monocytes.
Monoclonal IgM cold agglutinins (CA) bind and, in the presence of complement, are cytotoxic to various mammalian cells. The impact of these autoantibodies on functional capacity of phagocytes has not been studied until now. Herein we report that sera with monoclonal IgM anti-I and anti-i CA significantly reduce adhesiveness, phagocytosis, phagocytic index, and intracellular bactericidal activity of human peripheral blood polymorphonuclear cells (PMNs) at 37 degrees C and 24 degrees C. Anti-i CA were more active than anti-I. Sera with monoclonal IgMs without CA activity reduced the total number of ingested bacteria but otherwise had no effect on phagocytic functions. There was no difference in the degree of inhibition when anti-i and anti-I CA were tested against cord, maternal, and adult PMNs. Chromatographically purified a-I and a-i CA inhibited markedly phagocytosis in concentrations as low as 1 mg/ml. Phagocytic activity of peripheral blood monocytes was inhibited by CA at 18 degrees C but not at 24 degrees C or 37 degrees C. Pepsin digestion or reduction and alkylation of chromatographically pure IgM CA abolished completely their inhibitory activity. Thus, in physiological temperatures, monoclonal IgM cold agglutinins impair various phagocytic functions of human phagocytes. It may add to the susceptibility to infections in patients in which such autoantibodies are synthesized.
Agglutinins↗
Percutaneous drainage of intra-abdominal abscesses following abdominal trauma.
Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.
Abdominal Injuries↗
Congenital splenic cysts presenting after blunt abdominal trauma.
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Abdominal Injuries↗
Lower gastrointestinal hemorrhage in renal transplant recipients.
A review of the literature and our own series revealed 38 patients with lower gastrointestinal (LGI) hemorrhage among 4086 renal transplant recipients (0.9%). These patients represent 30% of 128 patients with major colorectal complications in this group. Of the 32 patients whose treatment and outcome were reported, only 12 (38%) were treated operatively. The overall mortality rate was 72%. The causes of LGI hemorrhage included colitis from opportunistic infections (42%); pseudomembranous, ischemic, or uremic colitis (40%); and idiopathic ulcers of the colon (18%). Colonoscopic, gross, and histopathologic findings of a patient with massive LGI hemorrhage from a fungal ulcer of the colon are the focus of this study, as are the implications of such findings. We propose an algorithm for diagnostic and therapeutic management decisions. We emphasize prompt diagnosis and the importance of colonoscopy. We propose withdrawal of immunosuppression and early operative intervention if the patient survival rate is to improve.
Candidiasis↗
Colonic lymphoma as a cause of massive rectal bleeding in a cardiac transplant recipient.
Lower gastrointestinal hemorrhage in immunosuppressed transplant recipients is associated with significant morbidity and mortality. This hemorrhage is often massive and frequently due to ulceration of the colon by opportunistic organisms requiring early diagnosis and resection. We report a heart transplant recipient with massive rectal bleeding from an unsuspected lymphoproliferative lesion of the sigmoid colon treated successfully with prompt surgical resection and reduction of immunosuppression. Although lymphoproliferative lesions are common in transplant recipients, particularly in those immunosuppressed with cyclosporine, we believe massive rectal bleeding to be a unique presentation of such a lesion.
B-Lymphocytes↗