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PubMed2001

[Lung and pleural ultrasound].

Palpable nodules at the chest wall (e.g. lymph nodes) and rib fractures can be characteristically visualized by ultrasound. The simplest method and most sensitive technique to image and measure pleural fluid is ultrasound. Sonographic evidence of pleural nodules is a specific finding in patients with malignant effusions. Peripheral pulmonary consolidations are visible by ultrasound if they extend up to the pleura. One can image pleuritis, pneumonia, lung cancers, pulmonary infarction, and atelectasis in typical sonomorphology, but limited specificity. Ultrasound guided transthoracic puncture is minimally stressfulfor the patient, is accurate, has a low rate of complications and is also cost effective.

Diagnosis, Differential↗
PubMedDate not supplied

[Research concerning the physiopathology of post-traumatic periarticular ossifications and anterior brachial muscle osteoma. Their prevention].

The author maintains that the osteoma of the brachial muscle as well as post-traumatic periarticular calcifications, occur in the muscle mass or in the tendon that prolongs it, or in the articular capsule, as a result of surgical treament and post-operative immobilization, and only exceptionally following orthopaedic treatment of traumatic lesions. Articular mobilization in the first week after osteosynthesis, or in the frame of conservative treatment, is not followed by osteoma of the brachial muscle or by calcifications surrounding the articulation, a fact that suggest that the presently applied therapeutic methods, which recommend strict and prolonged articular immobilization should be avoided. The development of ossification can be explained by post-traumatic changes in the muscular microcirculation, rendered more severe by surgical treatment and maintained by muscular inactivity. Early articular mobilization is the most efficient method of prophylaxis of these complications, which are determined not by the traumatic lesions themselves but by the present therapeutic methods applied.

Adult↗
PubMed2001

[Complete transection of the left main bronchus due to a blunt chest trauma: report of a case].

A 62-year-old man was injured in a traffic accident. A chest roentgenogram showed pneumothorax, hemothorax, subcutaneous and mediastinal emphysema, multiple rib fractures, and a shift of the trachea to the right. Bilateral thorax drainage was performed, and air leakage from a left chest tube was observed. A chest computed tomogram demonstrated stenosis and deformation of the left main bronchus. Bronchofiberscopy revealed complete obstruction of the left main bronchus by the left main pulmonary artery. An emergency thoracotomy revealed complete transection of the left main bronchus and laceration. End-to-end anastomosis of the left main bronchus was performed with interrupted 4-0 PDS II suture. The patient was discharged at the 33rd hospital day.

Accidents, Traffic↗
PubMed2001

Hemorrhagic shock due to intrathoracic rupture of an osteosarcoma of the rib.

A 13-year-old girl presented with dyspnea and chest pain. Chest radiography showed a massive left pleural effusion. Computed tomography revealed a tumor of the fourth rib. A large bloody effusion was drained. Her anemia worsened (hemoglobin: 4.8 g/dl), and hemorrhagic shock ensued. An emergency thoracotomy was performed. Bleeding from the ruptured tumor was identified. The fourth rib, the tumor, and the adjacent tissues were resected. Histopathologic examination revealed a ruptured primary osteosarcoma of the rib with pleural dissemination.

Adolescent↗
PubMed2001

Managing the pain of traumatic injury.

Management of pain in the trauma patient is a complex issue requiring the ability to selectively match different injuries and patient situations with the most optimal pain management methods. Having an understanding of the various stages of trauma care helps clinicians to best support the goals of patient care while decreasing the detrimental effects of the stress response through good pain control interventions. When nurses have a good understanding of the various pain management interventions they are better able to assess the effectiveness, potential side effects, and goals of therapy. The following is a list of clinical pearls to help guide nurses to better manage the pain of traumatic injuries: Encourage your trauma team to standardize pain medications (particularly opioids). A protocol that uses a couple of opioids with varving routes of administration, onset, duration, mechanism of action, and side effects helps the team to become extremely familiar with them and better able to assess effectiveness and side effects. Frequent motor and sensory assessments are necessary in the injured-patient (especially with extremity and head injuries), and drug therapy choices must allow for a thorough baseline assessment and periodic checks to follow. Patients with multiple rib fractures or flail segments (particularly elderly patients) and no contraindications deserve serious consideration for treatment with an epidural. When using various pain management techniques, the nurse needs to be prepared to treat complications if they should arise. Airway equipment, drugs (i.e., oxygen, opioid antagonists, pressors), and resuscitation means must be immediately available. Nurses need to be extremely careful when receiving pain medication and other central nervous system depressant orders from various doctors involved in patients' care. If a pain management specialist is involved, all pain medication therapies should be supervised and ordered by that individual, particularly when spinal analgesia is employed. Nurses must be knowledgeable regarding the effects of spinal medications (local anesthetics and opioids) at varying spinal levels so as to assess therapeutic as well as untoward effects. Institute a diligent bowel protocol when using opioids. Opioid administration combined with the immobility and altered nutrition often associated with trauma can easily result in constipation, abdominal distention, and bowel obstruction. It is not uncommon for epidural blocks to need supplementation with other drug therapy, and this should not be considered a failure of the epidural. Any addition needs to be ordered and closely supervised by one primary team of doctors. Use of nonopioid drugs, if not contraindicated should be considered in all trauma patients. This is especially true for patients sustaining trauma and being discharged to home within 24 hours. They need to be educated about the pain they can expect the next day and how to judge if it is normal and expected or possibly the sign of a missed injury or developing complication (i.e., compartment svndrome infection).

Aged↗
PubMed2002

[Sarcoidosis and clear cell carcinoma of the kidney: the sixth case?].

The Authors report a very rare case of clear cell renal cancer associated with sarcoidosis, incidentally discovered in a 39 year-old man, admitted for a not correlated pathology (multiple left rib fractures due to automobile crash). Problems related to a proper assessment of sarcoidosis are discussed as well as potential arising of a neoplasm during the entire follow-up period: for that, it must always be complete and accurate.

Adenocarcinoma, Clear Cell↗
PubMedDate not supplied

[Injury pattern in fatal automobile accident passengers due to rear-end collisions].

The article reports on the injury pattern seen in fatally wounded car passengers after rear-end collisions on motorways. The study material included 5 rear-end collisions, in which 9 car occupants (5 drivers and 4 front-seat passengers) were killed. The change in velocity (delta v) was above 60 km/h in all the reported cases. The injury pattern showed the following characteristics: extensive soft-tissue traumatization (subcutaneous haematomas, blood-filled pockets, "décollements") not discernible from outside on the back of the trunk, mostly in the lumbosacral region; dorsal serial rib fractures, often combined with fractures of the spine (including the sacrum and the coccyx) and/or the pelvis; ruptures of the aorta at the typical sites of predisposition; ruptures of the liver and spleen (particularly at the visceral surfaces).

Accidents, Traffic↗
PubMedDate not supplied

Transient hepatic attenuation differences (THAD) not connected to focal lesions.

PURPOSE: To report our experience with helical CT evaluation of transient hepatic attenuation differences (THAD), and in particular of those not associated with focal lesions, in an attempt to provide an aetiopathogenetic picture that accounts for the morphology, evolution and density of THAD. MATERIALS AND METHODS: Between January 1998 and January 2001 we observed THAD in 130/988 biphasic helical CT liver examinations performed in the arterial and portal dominant phase. THAD were associated to focal hepatic lesions in 87 patients; in 43 patients there was no such association. This second group of patients, composed of 23 males and 20 females ranging in age from 17 to 80 years (average = 58.8), was enrolled in the study. THAD were associated to: Budd-Chiari syndrome (9), portal venous thrombosis (10), liver cirrhosis (7), acute inflammation of an adjacent organ (4), dilatation of the entire biliary tree (3), hepatic stasis caused by heart failure (2) and constrictive pericarditis (1), fine-needle percutaneous biopsy (2), arterioportal shunting (2), parenchymal compression by fractured ribs (2) and by a strengthened phrenic pillar (1). THAD were evaluated according to extension, morphology and density. For each case at least 10 density measurements were performed by sampling regions of interest on the parenchyma with THAD and on the contralateral parenchyma. The results (mean and standard deviation) were compared to those relative to 30 healthy patients. 22/43 patients were followed up for 6#150;24 months by at least one US and helical CT examination. During CT, the direct appreciation of vascular thrombus during the portal dominant phase was also considered. RESULTS: We detected 18 localised and 25 diffuse THAD. The localised sectoral THAD (11), wedge-shaped with clear border sign, were associated to thrombosis of a portal branch (6), fine-needle percutaneous biopsy (2), arterioportal shunting (2) and partial Budd-Chiari syndrome (1). The localised non-sectoral THAD (7), with variable morphology and without the clear border sign, were associated to acute inflammation of an adjacent organ (4) and to parenchymal compression by the ribs or diaphragm (3). Diffuse THAD associated to Budd-Chiari syndrome (8) and to heart failure (3) showed mosaic enhancement of hepatic parenchyma (patchy pattern); those linked to portal trunk thrombosis (4) and cirrhosis (7) revealed predominant enhancement of external hepatic parenchyma (central-peripheral phenomenon); finally, those concurrent with dilatation of the entire biliary tree showed parenchymal enhancement close to the dilated bile ducts (peribiliary pattern). Follow-up (22/43) demonstrated complete THAD regression after removal (5/22) and less conspicuity of THAD after partial overcome of the stoppage (1/22). In 2/22 cases of arterioportal shunting no substantial changes were seen. The remaining 14/22 cases showed a gradual, slow tendency towards THAD regression with hypotrophy of the involved parenchyma and compensatory contralateral hypertrophy even in the case of endurance of the causative agents. CONCLUSIONS: Based on our experience and the literature we suggest a classification for THAD unrelated to focal hepatic lesions. We recognise 4 causes: portal vein stoppage-obstruction, portal in-flow diversion, trauma and inflammation. When THAD is related to the first three causes pathogenesis is portal hypoperfusion. In the fourth group the mediators of the arterial phenomena are those of inflammation even though portal hypoperfusion might be involved as well. THAD identification makes the detection of vascular thrombi easier by comparison with their direct finding during the portal dominant phase. Finally, THAD are to be investigated for their potential utility in the detection and characterisation of several hepatic diseases. As a consequence, hepatic CT studies cannot ignore arterial dominant phase evaluation, even if no focal hepatic lesions are expected.

Adolescent↗
PubMed1975

[Two cases of the traumatic rupture of the diaphragm (author's transl)].

Recently, the cases of traumatic rupture of the diaphragm increased due to traffic accidents increasing. We experienced two cases of this type of trauma in short breathing after traffic accidents. The chest roentgenograms on admission revealed multiple fractured ribs, homogenous density in the left thorax and mediastinal shift to the right side with the elevation of the left diaphragm, and the stomach were demonstrated in the left thoracic cavity by the method of nasogastric tube barium study. The transthoracic operation were performed following 7 hours after an accident on the first case. The omentum, splenic flexura of colon, stomach, small bowel, and spleen were herniated to the left thoracic cavity and the spleen was ruptured. The spleen was resected in the same field and the diaphragm rupture was closed with 8 figure stitch sutures. On the second case, also, the transthoracic operation were performed seven days after admission because of misdiagnosis for left hemothorax. Herniated stomach, colon, small bowel, omentum, and spleen were repositioned and diaphragm rupture was closed with 8 figure stitch sutures. Covalescence were smooth and the patients were discharged from the hospital on the 28th post operative days.

Hernia, Diaphragmatic, Traumatic↗
PubMed2002

[Medicolegal and compensation scientific approach to automobile accident].

Multiple injuries are frequently observed over the whole body of traffic victims in medico-legal autopsy cases. The assessment of a traffic casualty must include not only the victim but also the vehicle and the circumstances of the accident. Only consideration of all available data permits a better assessment of the mechanism of the crash and causation of injuries. J. M. Thevenet drove the first car carried from France to Japan on February 6, 1898. On October 28th, 1905, the first death by a road traffic accident occurred in Osaka. We performed a retrospective analysis of 279 traffic fatalities examined by medico-legal autopsy in Niigata that occurred over a twenty-two-year period from 1980 to 2001. All persons who had an ICD-10 code were grouped by 153 pedestrians, 43 pedal cyclists, 20 motorcycle riders, 45 car occupants, 11 occupants of pick-up trucks or vans, 4 occupants of heavy transport vehicles and 3 others. The average of ISS (injury scale score) is 40.7 in pedestrians, 26.7 in pedal cyclists, 32.4 in motorcycle riders, 25.1 in car occupants, 16.5 in occupants of pick-up trucks or vans, 24.0 in heavy transport vehicles and 69.0 in others. Rib fractures were observed in 170 cases (60.9%) and the frequency of other injuries was shown in Table 2. Criminal Punishment for drivers involved in 261 traffic accidents amounted to 35 sentences of imprisonment (13.4%), 46 suspension of execution of sentence (17.6%) and 60 sentence of fine (23.0%). Forty prone pedestrians run over by cars showed high ethanol levels in their blood. It was necessary to identify the driver of a vehicle in twelve car accidents and simulation with a computer is very useful. The average of ISS was 34.0 in ten drivers and 22.0 in fourteen fellow passengers. Four sudden natural deaths of drivers at the wheel, eight cases of death immediately after and from one day to five months after road traffic accidents, nine suicides and one intentional accident are excluded from traffic death. Both a medico legal and scientific compensation approach to automobile accident is now necessary.

Accidents, Traffic↗
PubMed2003

Experience in using three different minimally invasive approaches in cardiac operations.

BACKGROUND: In order to reach a clear understanding of minimally invasive approaches in cardiac operations, the authors review clinical experience in using three such approaches: inferior partial median sternotomy, right anterolateral minor thoracotomy, and the right parasternal approach. MATERIAL/METHODS: Sternotomy and the three different minimally invasive approaches were applied in and 2431 and 323 patients respectively. The approaches were selected according to the circumstances of the individual case. Both external and internal cardiac structures were observed during the operations. The length of the incision, the postoperative drainage, operative time, and cardiopulmonary bypass time were investigated. The postoperative complications occurring after minimally invasive approaches were observed. RESULTS: In inferior partial median sternotomy, all structures except for the ascending aorta could be exposed well. In right anterolateral minor thoracotomy, only the structures on the right side of the heart could be exposed, but the mitral valve could also be exposed well. The exposure of the right parasternal approach was similar to that of right anterolateral minor thoracotomy. There were statistically significant differences between sternotomy and the minimally invasive approaches in terms of incision length and postoperative drainage, but no difference in operative time and cardiopulmonary bypass time. The postoperative complications of MIAs included air embolism (n = 3), chest pain (n = 9), chest wall malacia (n = 1), rib fracture (n = 2), and sternum fracture (n = 2). The total incidence of complications in minimally invasive approaches was 5.3%. CONCLUSIONS: The minimally invasive approaches can have satisfactory clinical results if the approaches are correctly chosen and performed.

Adult↗
PubMedDate not supplied

[Causality of an accident in subsequent fatal pulmonary embolism a few hours after trauma].

An 87-year-old woman, who was largely immobilized in a wheelchair, suffered rib fractures and an unstable fracture of the pelvic ring in a fall. Approximately 2 1/2 hours later she developed marked clinical symptoms of pulmonary thromboembolism and died 5 hours after the accident. The question to be discussed with regard to the causality was the unusually short interval of only 2 1/2 to 5 hours between the accident and the clinical signs of embolism leading to her death. Current literature gives only rough outlines stating that thromboembolism can occur as early as the first day after the trauma. An alternative theory explaining the pulmonary thromboembolism may be the breaking off of a pre-existing thrombus due to manipulation during transport or diagnostic measures in connection with the unstable fracture of the pelvic ring.

Accidental Falls↗
PubMed1976

[Roentgenologic diagnosis of splenic trauma (author's transl)].

Description of radiologic criteria in splenic trauma. Abdominal plain film: Enlarged shadow of the spleen with blurred margins; elevation - or rupture - of the left diaphragm; homogenous radiodensity in the left hypochondriac region; fractures of ribs or transverse process. Angiography is indicated in doubtful cases to clarify the following lesions: contusion, sub-or extracapsular hematoma, rupture and fragmentation. Possible diagnostic errors in arteriography (63 examined cases) are discussed.

Adult↗