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This case report deals with a 68-year-old man in whom a contusion resulted in a complete loss of the iris through an Elliot fistula. The abrupt increase in intraocular pressure caused the iris to be extruded through the fistula and the ruptured conjunctiva. A functional drainage bleb was reconstructed by pulling and suturing subconjunctival tissue underneath the ruptured conjunctiva.
In a retrospective study, 87 patients were reexamined after hospital treatment of ocular contusion. The relationships between intraocular pressure, outflow facility, and lesions of the anterior chamber angle were analyzed. In 52% of the cases, lesions were demonstrated in the anterior chamber angle; about half of these patients showed extension of 180 degrees or more. There was no statistical correlation between intraocular pressure and outflow facility or the extent of anterior chamber angle lesions, although clinical findings clearly indicated such correlations. Blunt ocular injuries evidently lead to higher intraocular pressure in elderly patients. The latency period also appears to play a role: the longer the period between trauma and examination, the higher the pressure measured in the injured eyes. We found secondary glaucoma in two cases (about 2%). Glaucoma was suspected in six patients (6.5%). There was an apparent risk of glaucoma in four patients (4.3%).
The case of a fracture of the clivus in a 10-year-old boy following a road traffic accident is reported. He also suffered a contusion of the cerebellar vermis and the management dilemma in this case is highlighted. Fracture of the clivus in a child is extremely rare; this is the second reported case and the first reported with survival.
The protective effect of chlorpromazine on rat spinal cord injury was investigated using a dynamic impact model. A 10 g weight was dropped 5 cm on an impounder placed on the exposed spinal cord at the T-11 level. Changes in potassium concentration on the epidural surface of the injured spinal cord were measured using a combined impounder-K+ electrode assembly. Recovery of motor performance was estimated using the modified Tarlov score. In the injury control (no treatment) group, the recovery was slow. Animals were still paralyzed 4 weeks after injury and none of them could walk; the Tarlov score was 1.88 +/- 0.78 (S.D.). In contrast, the chlorpromazine-treated group (20 mg/kg i.p. 30 min prior to injury) recovered significantly in 4 weeks. Animals could either support body weight or walk with some deficit; the Tarlov score was 4.0 +/- 0.35. Chlorpromazine inhibited potassium efflux from the spinal cord after contusion. Possible mechanisms of protection of neural cells by chlorpromazine are discussed.
The role of Ca2+ in cellular injury has received particular attention in studies of acute spinal cord trauma. In this context, the spatial and temporal distribution of extracellular Ca2+ ([Ca2+]e) may have an important bearing on the development of secondary tissue injury. We therefore studied the spatial-temporal distribution of [Ca2+]e following moderate (25 g-cm) contusive injury to the rat thoracic (T9-T11) spinal cord. Double-barreled, Ca(2+)-selective microelectrodes were used to measure the magnitude and time course of [Ca2+]e at increasing depths from the dorsal spinal cord surface. After 2 h, the tissue was frozen and later analyzed for total Ca concentration using atomic absorption spectroscopy. [Ca2+]e fell at all depths, but the decrease was maximal at 250 and 500 microns from the dorsal surface, where, at 0-10 min after injury, [Ca2+]e averaged 0.09 +/- 0.03 and 0.06 +/- 0.03 mM respectively. By 2 h postinjury, [Ca2+]e recovered to nearly 1 mM across all depths. Over this time, total tissue calcium concentration ([Ca]t) was 4.54 +/- 0.16 mumol/g in injured cords vs 2.75 +/- 0.1 mumol/g in sham-operated controls. These data place emphasis on the dorsal gray matter as a principal site of ionic derangement in acute spinal cord injury. The implications of these findings are discussed with reference to secondary injury processes.
Astrocytes become reactive as a result of various types of lesions and upregulate 2 intermediate filaments, glial fibrillary acidic protein (GFAP), and the developmentally regulated protein vimentin. Young female Sprague-Dawley rats were subjected to a spinal cord contusion at segment T10 using the New York University injury device. Animals were killed at 1, 2, 7, 14, and 30 days postinjury. Horizontal spinal cord sections spanning segments T7-T13 were assessed with antibodies to both intermediate filament proteins. The number of gray matter GFAP-positive astrocytes increased by 2 days postinjury, with segments adjacent (proximal) to the injury site showing greater responses than areas several segments away (distal). By 30 days following injury, astroglial cell numbers returned to normal levels. Vimentin-positive astrocytes also showed a graded proximal/distal response by 2 days following injury. Proximal regions remained significantly higher at 30 days following injury than control animals. Rostral/caudal changes were also evident, with regions caudal to the injury showing significantly higher numbers of vimentin positive astrocytes than those rostral, indicating that gray matter areas caudal to spinal cord injury may undergo more stress following spinal cord injury.
A retrospective analysis of all patients with traumatic thoracic aortic rupture (TAR) admitted to the hospital over a consecutive 10-year period was performed in order to define the incidence, morbidity, and mortality of associated cardiac contusion (CC) in patients with TAR. Of the 13 patients with TAR, eight (62%) had associated CC. All patients with CC had two or more of the following positive findings: abnormal ECG, elevated myocardial-band creatinine kinase levels, abnormal radionuclide angiography/left ventricular segmental wall motion studies, or cardiac damage seen at surgery and postmortem examination. Four patients with TAR suffered cardiac arrest; all of the latter patients had associated CC. After successful repair of the TAR, five of six patients with combined TAR and CC developed adult respiratory distress syndrome (ARDS), whereas only one of five patients with isolated TAR had ARDS. All patients with isolated TAR survived, whereas three of eight patients suffering combined TAR and CC died perioperatively, secondary to cardiac arrest. In patients with TAR, the presence of associated CC occurs with increased frequency, is associated with increased morbidity (cardiac arrest, ARDS), and results in increased operative mortality secondary to cardiac instability. A branch-chain decision tree (clinical algorithm) was developed as a means of improving management of patients with combined TAR and CC, including indications for preoperative pulmonary artery catheterization.
One hundred twenty-five consecutive patients with a diagnosis of blunt chest trauma underwent T1-201 thallous chloride single photon-emission computed tomography (SPECT) scan, as well as physical examination, serial ECG and cardiac enzymes. A subset of patients had 24-h Holter monitoring. SPECT scan was performed within 24 h of injury. Seventy-five patients had positive scans and 48 had negative. Two studies could not be completed. Eleven patients with positive studies developed serious arrhythmias (multiple premature ventricular beats or atrial fibrillation). None of these patients had a prior history of cardiac disease. While three patients with negative SPECT scans had arrhythmias, each had a prior history of cardiac disease and two were on chronic antiarrhythmia therapy. Neither ECG findings, creatinine phosphokinase (CPK), nor CPK-isoenzymes distinguished between those patients who did and did not develop arrhythmias. We conclude that SPECT scan is useful in screening patients at risk of developing arrhythmias from cardiac contusion. Utilization of SPECT scan allows early discharge of a significant number of patients with blunt chest trauma who would otherwise require hospitalization for arrhythmia monitoring.
Contusion is a rare cause of acute compartmental syndrome in the thigh. To date, no case report has described blunt trauma precipitating this limb-threatening condition. The patient in this case report developed rapidly progressive signs and symptoms which required emergency fasciotomy. Delayed primary closure was possible and recovery was complete. The etiologies, diagnosis and management of thigh compartmental syndrome are reviewed.
A patient with myocardial trauma following blunt chest injury is presented who returned 4 months later with persistent cardiac symptoms. Left ventriculography showed asynergy of the mid-diaphragmatic surface of the left ventricle while coronary angiography showed normal coronary arteries. The value of cardiac catheterization and coronary angiography in patients in whom symptoms persist after traumatic myocardial contusion and in patients in whom additional coronary artery or other cardiac disease is suspected is emphasized.
Two patients who sustained cardiac contusions secondary to blunt chest trauma developed refractory cardiogenic shock. Use of intra-aortic balloon counterpulsation improved circulatory dynamics in each case and one patient survived. Requirements for inotropic agents were diminished or eliminated, cardiac output was increased, acidosis was reversed, and the electrocardiogram reverted to normal. Although balloon counterpulsation is most effectively employed in patients with ischemic cardiac deficits, its early application coupled with appropriate pharmacologic treatment is also effective in raising low cardiac output that results from myocardial trauma.
Four patients are presented who sustained blunt trauma and later developed necrotizing fasciitis in the areas of contusion, associated with the distant locus of sepsis. Three of the cases developed acute renal failure and later died. Early recognition of this condition allows prompt debridement beyond the margins of involved necrotic fascia, followed by wound inspection 8-hourly, and treatment with antibiotics, most recently third-generation cephalosporins, piperacillin, amikacin, and vancomycin.
Utilizing a double-lumen endobronchial tube, synchronized independent lung ventilation (SILV) was successfully employed to manage severe unilateral pulmonary contusion in a 6-year old trauma patient. This appears to represent the youngest reported patient in whom this technique has been utilized. Early institution of this treatment modality may substantially increase survival.
STUDY DESIGN: The effect of spinal canal narrowing and the timing of decompression after a spinal cord injury were evaluated using a rat model. OBJECTIVE: To evaluate whether progressive spinal canal narrowing after a spinal cord injury results in a less favorable neurologic recovery. Additionally, to evaluate the effect of the timing of decompression after spinal cord injury on neurologic recovery. SUMMARY OF BACKGROUND DATA: Results in previous studies are contradictory about whether the amount of canal narrowing or the timing of decompression after a spinal cord injury affects the degree of neurologic recovery. METHODS: Forty adult male Sprague-Dawley rats were equally divided into a control group, in which spacers of 20%, 35%, and 50% were placed into the spinal canal after laminectomy, and an injury group in which the spacers were placed after a standardized incomplete spinal cord injury. After spacer removal, neurologic recovery in both was monitored by Basso, Beattie, Bresnahan (BBB) Locomotor Rating Scale (Ohio State University, Columbus, OH) motor scores and transcranial magnetic motor evoked potentials for 6 weeks followed by histologic examination of the spinal cords. Subsequently, 42 rats were divided into five groups in which, after spacer placement, the time until decompression was lengthened 0, 2, 6, 24, and 72 hours. Again, serial BBB motor scores and transcranial magnetic motor evoked potentials were used to assess neurologic recovery for 6 weeks until the animals were killed for histologic evaluation. RESULTS: Spacer placement alone in the control animals resulted in no neurologic injury until canal narrowing reached 50%. All of the control groups (spacer only) exhibited significantly better (P < 0.05) motor scores compared with the injury groups (injury followed by spacer insertion). Within the injury groups the motor scores were progressively lower as spacer sizes increased from the no-spacer group to the 35% group. The results in the 35% and 50% groups were not statistically different. The results of the time until decompression demonstrated that the motor scores were consistently better the shorter the duration of spacer placement (P < 0.05) for each of the time groups (0, 2, 6, 24, and 72 hours) over the 6-week recovery period. Histologic analysis showed more severe spinal cord damage as both spinal canal narrowing and the time until decompression increased. CONCLUSION: The results in this study present strong evidence that the prognosis for neurologic recovery is adversely affected by both a higher percentage of canal narrowing and a longer duration of canal narrowing after a spinal cord injury. The tolerance for spinal canal narrowing with a contused cord appears diminished, indicating that an injured spinal cord may benefit from early decompression. Additionally, it appears that the longer the spinal cord compression exists after an incomplete spinal cord injury, the worse the prognosis for neurologic recovery.
Isolated sternal fractures are seen with an increasing frequency in traffic road accidents especially after the introduction of the seatbelt legislation. In most cases, the victims are young, otherwise healthy individuals. The medical records of all patients who were treated with a diagnosis of sternal fracture over the past 10 years were retrospectively reviewed. All patients with a radiologic diagnosis of sternal fracture were admitted for cardiac monitoring for at least 24 hours. ECG, determinations of cardiac enzyme levels CK (creatinephosphokinase) and CK-MB and evaluation by a cardiologist were routinely performed. An echocardiography was performed when indicated by the cardiologist. A total of 86 patients had sustained a sternal fracture during the 10-year study period. There were 39 males and 47 females with a mean age of 50 years (range 15-97 years). Serial 12-lead electrocardiograms, which were performed in 83 (97%) patients, revealed no information about myocardial contusion or cardiac arrhythmias with consequent therapy. In eight patients, a significant elevation in cardiac enzyme levels (elevation of CK-MB fraction above 10% of CK) was observed. All were normalized within 24 hours without development of any arrhythmias. Echocardiography was performed in 31 patients. In two patients, dyskinesia of the right ventricle (without enzyme elevations or arrhythmias) was observed. Within 24 hours these abnormalities resolved. The cardiac rhythm was monitored in 61 (71%) patients for a total of 1550 hours. No arrhythmias were observed. The cardiac enzyme studies, ECG and echocardiography revealed no consequent information about arrhythmias. In case of a sternal fracture, we recommend a chest X-ray to exclude other associated intrathoracic injuries. If no abnormalities are identified, admission to hospital is not necessary.
Multidetector computed tomography (MDCT) cardiac findings in an unconscious teenager after blunt chest trauma are presented. Multidetector computed tomography enabled accurate comprehensive evaluation of the coronary arteries, myocardial perfusion, and left ventricular function. This case illustrates the full capabilities of MDCT in the evaluation of cardiac contusion in a noncooperative pediatric patient.
BACKGROUND: Blunt chest trauma is an important clinical problem leading to injury of the heart and lungs that may be fatal. Experimental models in large animals have been developed previously. This study was aimed at developing a small-animal (rat) model for the purpose of evaluating blunt chest trauma. METHODS: Blunt trauma was delivered to the left side of the chest in rats by a captive bolt handgun. The gun was modified so that the amount of energy delivered to the chest wall could be adjusted. The injury energy varied from 1.7 to 6.8 J. Thirty-eight experiments in adult rats were performed. Electrocardiographic monitoring was performed continuously to determine cardiac rhythm. Gross and histologic examination of lungs and heart was performed at the time of death resulting from injury or euthanasia up to 13 days after injury. RESULTS: Some form of cardiac arrhythmia accompanied blunt chest trauma in every case. Serious ventricular arrhythmia (tachycardia or fibrillation) was nearly always fatal (15 of 16 cases), but gross or histologic evidence of cardiac injury was present in only 31% of fatal cases. Lung injury (often bilateral) as shown by atelectasis and hemorrhage into the parenchyma or airway was found in 93% of the experiments when medium range energy force was applied. CONCLUSION: This study has established a useful model for the study of blunt chest trauma in a small animal (rat). Blunt chest trauma is associated with cardiac arrhythmia, which may be fatal. Injury to the heart may not correlate with serious cardiac arrhythmia resulting in death, lending credence to the concept of cardiac concussion or commotio cordis. Lung contusion is always more obvious than morphologic injury to the heart.
We report a severe head injury and blunt chest trauma with sternal and multiple rib fractures with high-energy impact in a 22-year-old man. Twelve hours after the accident, haemodynamic status of the patient rapidly worsened because of right ventricular (RV) failure due to myocardial contusion, requiring increasing doses of catecholamine. Nitric oxide inhalation was used to decrease RV afterload, and produced an immediate improvement in haemodynamic status, permitting a decrease in catecholamine administration. From days 2 through 8, cardiac function continued to improve, and was normal on day 9. Nitric oxide inhalation was stopped on day 4.