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PubMed1996

[Traumatic rupture of the thoracic aorta].

This is a retrospective analysis of 50 postraumatic aortic rupture (1968-1996, 39 males, mean age: 34.5). Group A is composed of 35 patients with an acute aortic rupture and a prompt diagnosis. Group B includes 13 patients with a chronic rupture. All patients from group A had a severe politraumatism with abdominal, cranial, extremities or hip fractures. Mediastinal thickening with or without hemothorax indicated an angiography or a transesophageal echocardiography lately. In group A, 36 patients have been operated on urgently (12-24 hours); cardiopulmonary bypass was performed on 20 patients; an aorto-aortical bypass was done in 27 cases and a direct suture in the remaining 9. In group B, cardiopulmonary bypass was performed on 9 patients; a aorto-aortical bypass was done in 11 cases and a direct suture in 2. Overall hospital mortality was 16%; 19% in group A and 7.6% in group B. Ischemic paraplejia appeared in 5 patients (10%), all from group A. No false aneurysm developed after 4.5 years of follow-up (3-135 months) in the 38 survivors. The usefulness of transesophageal echocardiography, the importance of medular protection and the utility of several interventionist radiologic techniques are discussed.

Adolescent↗
PubMedDate not supplied

Diagnosis and treatment of blunt cardiac rupture.

Blunt cardiac rupture is rare, but when it does occur it is almost immediately fatal. In patients surviving the initial insult, the overall mortality rate is 60%-90%. Patients typically present with either cardiac tamponade or massive hemothorax. We report a case of blunt cardiac rupture in a young male who had prolonged transfer time with survival. He presented with an intact pericardium and cardiac tamponade. In stable patients, the diagnosis can be confirmed with emergent echocardiography prior to operative intervention. If unstable, then subxiphoid pericardial window is both diagnostic and therapeutic. The repair is approached via either a left anterior thoracotomy or median sternotomy. The incision is usually dictated by the physiologic status of the patient at presentation. We conclude that patients with blunt cardiac rupture can be saved, especially those with vital signs are still strong when treatment is begun. Early diagnosis is the key to survival for patient with this rare condition.

Accidents, Traffic↗
PubMed1997

[A case report of spontaneous hemopneumothorax].

A 55-year-old man was admitted to the private hospital with chief complaints of left chest pain and increasing dyspnea. Chest X ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid of 1,000 ml was drainaged. So was the patient transferred to our hospital for surgical treatment. Following blood transfusion because of hemorrhagic pleural fluid of 1,500 ml, urgent surgery was carried out. At the operation under thoracoscope, the bleeding from the apex of the thoracic cavity was noted. The bleeding was controlled with endoscopic surgical clip. As it was, however, very difficult to remove massive blood clots under endoscopic surgery, a small thoracotomy was carried out in addition to the thoracoscopic surgery, then the bulla in the apex of left lung was resected and also removed a large amount of blood clots.

Hemopneumothorax↗
PubMed1996

[Percutaneous transthoracic drainage in pleural collections--the pros and cons from the surgical viewpoint].

An attempt is made at specifying the indications for inserting percutaneous transthoracic drain after Seldinger's method. The clinical case material analyzed for the purpose covers 761 patients over a three-year period (1993 through 1995), with 329 of them drained for pneumothorax, 266--hemothorax, and 66--hemopneumothorax. In 54 cases (7.1 percent) switching to surgical draining is necessitated, in 41 (5.39 percent) correction of the drain is done because of inefficiency, and in 96 (12.61 percent)--patency checking and its restoration on the serioscope table. A classification of pathological pleural collections is suggested which proves helpful in estimating whether or not a tube thoracic or percutaneous drain should be employed. The surgeon is cautioned that his assessment should be by no means influenced by the easier procedure under the excuse that it is the method of choice for the patient. Last but not least, one should give due consideration to the financial aspects: percutaneous drainage of the pleural cavity costs about 80 DM, whereas a cigarette thoracic drain costs about 100 leva at the time of analyzing the material.

Adolescent↗
PubMed1997

[Initial resuscitation of closed thoracic trauma].

Blunt thoracic trauma are frequent and often severe. Their management is improved in the prehospital settings by the involvement of a medical team, and the admission in a specialized trauma center. Diagnostic and therapeutic steps are closely linked. They are based on the stabilization of life threatening problems and the appropriate use of recent advances in medical imaging. Endotracheal intubation and mechanical ventilation are indicated for respiratory distress. Immediate surgical management is mandatory for an hypovolemic shock related to massive hemothorax. On the contrary, multiple ribs fractures and flail chest without major pulmonary contusion are managed with regional analgesia allowing effective physiotherapy and avoiding the infectious complications related to prolonged mechanical ventilation.

Emergency Medical Services↗
PubMedDate not supplied

Hemopericardium from coronary artery laceration complicating extracorporeal membrane oxygenation.

OBJECTIVE: We report the clinical course and successful surgical treatment of hemopericardium resulting from coronary artery (CA) laceration in two patients with congenital diaphragmatic hernia (CDH) undergoing extracorporeal membrane oxygenation (ECMO) bypass. STUDY DESIGN: Retrospective case review. RESULTS: Two neonates with CDH had needle aspiration for either pneumothorax or pericardial effusion before initiation of ECMO. While on bypass, progressive hemopericardium led to narrow pulse pressure and decreased venous return that limited bypass flow. Widened cardiac silhouette on chest radiographs suggested hemopericardium; echocardiography was confirmatory in one case. The underlying diagnosis of CA laceration was made during pericardiotomy and treated with surgical patching. CONCLUSIONS: Pre-ECMO history of cardiothoracic needle aspiration is important because complications such as hemothorax or hemopericardium may arise once ECMO bypass is initiated. Inadvertent CA laceration may lead to acute hemopericardium, compromising venous drainage. However, CA laceration can be successfully repaired while the patient is on bypass.

Coronary Vessels↗
PubMed1997

[Diagnosis of pleurisy].

Diagnosis of pleural effusion, suggested by chest pain or dyspnea, is assessed by physical examination, chest X-ray sometimes completed by other imaging techniques, and mainly by thoracentesis. Thoracentesis is mandatory for the diagnostic of pleural effusion as three diagnosis are associated with an emergency treatment: pulmonary embolism; hemothorax; empyema. If the fluid is a transudate, no further invasive studies are necessary. If the cause of pleural exsudat cannot be established by a careful history, physical examination and fluid analysis, generally closed pleural biopsy should be done, followed, in absence of an established diagnosis, by thoracoscopy. At this time, less than 10% of the cases remain without explanation, leading to a careful follow-up of patients since a carcinomatous lesion may develop in 1/3 of them.

Biopsy, Needle↗
PubMed1997

[Re-expansion pulmonary edema after emergency thoracotomy for spontaneous hemopneumothorax: a case report].

A 44-year-old man was admitted to out hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. Following blood transfusion because of 2,000 ml hemorrhagic pleural fluid, emergent surgery was carried out. At operation, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noticed. After extubation of endotracheal tube, he offered severe dyspnea with hypoxia. The chest X-ray showed figure of pulmonary edema in the left lower lobe. Patient was managed by oxygen, steroid, and urinastatin. On the 3rd operative day, pulmonary edema was disappeared. It should be kept in the mind that the re-expansion pulmonary edema occurred in patients with spontaneous hemopneumothorax of less than 3 days of duration.

Adult↗
PubMed1997

[A case of traumatic cardiac contusion accompanied by the rupture of pericardium].

We experienced a case of traumatic cardiac contusion accompanied by the rupture of the pericardium after multiple blunt trauma sustained in a traffic accident. A 26-year-old woman who had suffered from blunt chest and abdominal trauma was admitted to our hospital, being unconscious with multiple severe injuries including pelvic fracture, bilateral hemothorax, and multiple fractures in the extremities. The patient was in a shock status. We performed the transcatheter arterial embolization of the internal iliac arteries to control the bleeding, when aortography showed that the contrast media extravasated toward the left thoracic cavity. Immediately, an operation for blunt chest trauma was performed. Blood was flooding out of the ruptured pericardium because of the contusion of myocardium. The postoperative course was uneventful. Blunt chest trauma is usually accompanied by multisystem injury. Therefore, it is imperative to determine the priority of treatment based on preoperative examination in patients having multiple injuries.

Abdominal Injuries↗
PubMed1995

Diseases of the pleura.

In this review, three aspects of pleural disease are discussed. Although it was thought for many years that the origin of pleural fluid was the capillaries in the parietal or visceral pleura, recent evidence suggests that in many cases the origin of pleural fluid is the interstitial space of the lung. The interstitial space of the lung appears to be the source of the pleural fluid in patients who have congestive heart failure, parapneumonic effusions, pulmonary embolism, and lung transplants. The Hantavirus pulmonary syndrome is characterized by rapidly progressive, noncardiogenic pulmonary edema in relatively young, previously healthy individuals. The mortality rate with this syndrome is approximately 60%, and at autopsy most patients have large pleural effusions. Patients after lung transplantation frequently have profuse drainage from their chest tubes because most of the fluid that enters the lung must exit through the pleural space. The incidence of pleural effusion is very high in patients who have a complication of their lung transplantation, but the pleural fluid findings in patients after lung transplantation have not been well studied. Similarly, virtually all patients who undergo liver transplantation have a right-sided pleural effusion. The effusion usually reaches its maximum size around the third postoperative day. If the effusion increases in size after this time, serious complications should be suspected. The approach to pleural diseases has been altered with the advent of videothoracoscopy. Videothoracoscopy should be considered in patients who have undiagnosed pleural effusions and are not improving; in patients who have had recurrent pneumothorax, or a spontaneous pneumothorax with a persistent airleak or unexpanded lung; or in patients who have a traumatic hemothorax with clotted blood.

Endoscopy↗
PubMed1997

[Computed tomography in injuries to the respiratory system in children. The correlation with adults].

INTRODUCTION: Diagnostic imaging in emergency rooms may be inadequate and delayed, which makes chest traumas in children more severe and difficult to treat. We carried out a retrospective study on adults and children who had survived major chest traumas involving the respiratory tract to assess the differences between the two age groups and the role of emergency CT. MATERIAL AND METHODS: Our series consisted of fourteen children admitted to the emergency department for various accidents. Home accidents prevailed (9/14 = 64.3%). On admission, chest radiography was performed in most cases (11/14 = 78.6%); CT was carried out in 21.4% (3/14 patients). RESULTS: Trauma involved more organs in pediatric patients (11/14 = 78.6%) and lung involvement was always associated with other types of injury, namely contusion (14/14 = 100%), pneumothorax (11/14 = 78.6%), hemothorax (10/14 = 71.4%), tear (4/14 = 28.6%). CT corrected or integrated the radiographic findings of contusion focus in 67% (8/14) and that of pneumothorax in 63.6%; both patterns cannot be demonstrated otherwise. DISCUSSION: Mixed and multiple posterior parenchymal injuries with no rib fractures prevail in young subjects because their bones and ligaments are more elastic, which may lead to trauma underestimation. Tracheobronchial ruptures and pneumomediastinum are much more severe in children than in adults. Chest plain film is often the only diagnostic tool used, despite its major technical and interpretative limitations, also because skull and abdomen are the most investigated regions. Executive limitations are stronger in childhood, increasing the margin of error and the risk of delayed treatment. CT is as cost-effective as radiography and shows even the injuries missed or poorly depicted on conventional images; CT also gives accurate information on damage severity and nature. CONCLUSIONS: Traumatic injuries are more severe in pediatric patients due to their build and to biomechanical, clinical and management factors. Spiral CT should be considered the examination of choice to be performed in the emergency department equipped also for pediatric re-animation.

Accidents, Home↗
PubMed1976

[Intraoperative autotransfusion in gynecology and surgery (author's transl)].

The technique of intraoperative autotransfusion (AT) is being used to date only in a few individual clinics. Since there is a clinically safe and economical AT-apparatus available the routine application of this rational blood replacement method is easy to perform. The authors have used this technique altogether in 111 patients, applying the Bentley-ATS-machine in the last 69 cases. In a previous series of 42 cases AT was used for ruptured ectopic pregnancy, in the series of 69 surgical cases for hemothorax or intraabdominal hemorrhages of mainly traumatic origin. The most frequent indications for AT in emergency surgical operations were ruptures of spleen and liver, and in elective surgery for portocaval shunt. Altogether 247 litres of blood have been retransfused with an AT-volume per patient ranging from 0,5 to 15 litres. For anticoagulation generally ACD was used, only in vascular surgery was heparin preferred. Methodical complications have not been seen. Technique, indications, consequences and possible complications of AT are described. The main advantages of autologous intraoperative transfusion are the immediate availability of blood, the absence of the risk of hepatitis and of incompatibility reactions, reduction of pressure on the blood banks and lower transfusion costs. The authors therefore believe that the possibility of intraoperative AT should exist at every surgical and gynecological clinic.

Abdominal Injuries↗
PubMed1997

[Cannulation of the internal jugular vein under control of USG imaging].

The internal jugular vein cannulation is a commonly used route for access to the central venous system for therapeutic and diagnostic purposes. Although the great majority of this venous puncture are successfully performed using anatomic landmark technique, serious complication such as pneumothorax, arterial puncture or hemothorax can occur during this procedure, particularly under difficult clinical condition. A simple, ultrasound-guided technique has been developed using a portable scanner with transducer optimized for venous access. The authors experience in over 100 cases of ultrasound-guided central venous cannulations has been described. Ultrasound guidance reduces the number of passes needed to puncture the vein, increases the success rate of venous puncture, and minimizes complications. Ultrasound guidance is usually successful in allowing performance of internal jugular vein cannulation when landmark technique fail.

Catheterization, Central Venous↗
PubMed1998

[Permanent vascular catheters for extracorporeal dialysis. Preliminary study: Canaud and Tesio catheters].

The use of alternative permanent vascular accesses has recently become increasingly common. The possibility of using the catheterization of central venous vessels has therefore been taken into consideration, in particular the internal jugular vein. During an observation period of 32 months the catheterization of the internal jugular vein (IJV) was used as a definitive access in 34 patients (12 M, 22 F; mean age 67.5, mean dialytic age 56 months in 18 patients, in 16 patients the insertion was by primary intention). A total of 44 IJV catheters were used, of which 18 Tesio and 26 Canaud. The authors examined the immediate complications following insertion and the episodes occurring during the observation period, including the problem of infection. The insertion of catheters was possible in all cases. In terms of catheter function, blood flow was adequate for the various purifying techniques. No severe complications were reported: gaseous embolism, pneumothorax, hemothorax, hemomediastinum. Infection was observed in 11 patients and 13 catheters, of which 70% were mainly provoked by Staphylococcus aureus and epidermidis. During the observation period there was a drop-out of 14 patients, 11 of whom died (3 following sepsis that failed to respond to antibiotic therapy). This preliminary experiment shows that permanent jugular catheters may be regarded as a valid access for hemodialytic treatment both in patients with severe problems of vascular access and for patients who present a short-term prognosis of dialysis and life expectancy at the time of starting hemodialysis.

Adult↗
PubMedDate not supplied

Acute dissection of the thoracic aorta: experience at the Puerto Rico Medical Center (1991 through 1995)

BACKGROUND: Acute dissection of the thoracic aorta has a very poor prognosis unless promptly diagnosed and treated. The clinical presentation, diagnosis and management of 16 patients was reviewed. METHODS: We identified 12 patients from the Puerto Rico Medical Center and 4 patients from the "Centro Cardiovascular de Puerto Rico y del Caribe" whose diagnosis was made from January 1991 to December 1995. Medical records and autopsy reports were reviewed. RESULTS: Of the 16 patients, 10 [62%] were males, 10 [62%] were 60 years old or older [range 25 to 85 years], and 15 [93%] had a past history of hypertension although only 6 [38%] were found with an initial blood pressure of 140/90 or higher. Chest pain was the initial symptom in 13 [81%]. Of these 46% [6/13] described it as oppressive, with radiation to back or neck in 38% [5/13]. In none a neurological abnormality was the initial presentation. No physical sign was present in more than 40% of patients. One patient had a diastolic murmur suggestive of aortic regurgitation but none had a pericardial rub or a neurologic deficit. The electrocardiogram showed left ventricular hypertrophy in 35% but none had changes compatible with an acute Q wave infarction. The chest radiography was compatible with dissection in all in whom it was done [8/8]. Computerized tomography of the chest was diagnostic in 6 of 8 patients [sensitivity 75%]. Aortography had a sensitivity of 80% [4/5]. Trans-thoracic echocardiogram was diagnostic in 3 of 4 patients [75% sensitivity]. Transesophageal echocardiogram had a 100% sensitivity [2/2]. In 8 patients [50%] the correct diagnosis was made by postmortem examination, all of whom died within 24 hours of Emergency Room's evaluation. Of those properly diagnosed 5 died without being surgically intervened. Only one survived surgery [1/3] Overall mortality was 93%. The most common pathological finding was Type A dissection in 14 [88%]. Cardiac tamponade was found in 9 [56%]. Hemothorax was found in 6 [38%]. Aortic valve insufficiency was reported in 20% and coronary artery involvement in 28%. CONCLUSIONS: The dismal prognosis traditionally associated with acute dissection of the thoracic aorta remains unchanged. Prompt diagnosis based on high clinical suspicion. followed by expeditious medical and surgical treatment are fundamental to change the natural course of this condition.

Acute Disease↗
PubMed1998

[A case of pulmonary arteriovenous fistula beneath the surface of the lung].

A 19-year-old woman complaining of exertional dyspnea was admitted to our hospital with an abnormal shadow on the left side of the chest. Laboratory examination revealed polycythemia and hypoxemia. Pulmonary angiogram demonstrated a pulmonary arteriovenous fistula beneath the surface of the left S10. Partial resection of the left S10 was performed. The wall of the arteriovenous fistula was flimsy and seemed to rupture easily. The sister of this patient also had a peripheral pulmonary arteriovenous fistula and suffered from repeating epistaxis. Rendu-Osler-Weber disease was diagnosed in both, and the sister underwent partial resection of the right S7, which contained the fistula. Their postoperative courses were uneventful. Hemothorax and hemoptysis are lethal complications of arteriovenous fistulae. In order to avoid the rupture of fistulae, surgical resection is the most reliable treatment. Pulmonary arteriovenous fistulae beneath the surface of the lung should be resected.

Adolescent↗
PubMed1998

Porous diaphragm syndromes.

Porous diaphragm syndromes are a group of seemingly disparate clinical symptom complexes involving a wide variety of unrelated medical specialties. However, they are linked by a common anatomical feature, a defect in the diaphragm. They usually present with thoracic symptomatology--pleural effusions, pneumothorax, hemothorax, empyema--mediated by this defect. Management of these syndromes utilizes principles of thoracic surgical practice including thoracotomy and thoracoscopy.

Body Fluids↗
PubMed1976

Gunshot wounds of the esophagus.

During a 4 year period between 1970 and 1974 there were eleven esophageal gunshot wounds representing 52 per cent of the total esophageal perforations. The increased incidence of esophageal gunshot wounds reflects the higher rate of civilian gunshot injuries. There were six perforations in the cervical portion of the esophagus and five in the thoracic portion, with three located above the aortic arch, one in the midesophagus, and one in the lower third. Symptoms are less diagnostic than in esophageal perforations from other causes because the gunshot wound tends to mask the complaints related to mediastinitis. The signs are similar. In 9 patients free air was present in the neck or mediastinum and in 10 patients the diagnosis was confirmed by barium swallow. Of the 2 patients without free air, one had a lateral thoracic wound and esophageal injury was not suspected; the diagnosis was made by drainage of oral feeding through a thoracostomy and confirmed by barium swallow. In the other patient the perforation was found during surgery for hemothorax. Primary repair with drainage was done in the group with cervical injuries. All survived with no serious complications. In the group with thoracic injuries, fistulas developed in 2 of 3 patients who had primary repair with drainage. Two patients with extensive injuries of the esophagus treated by defunctionalization did well but required a second procedure. It is concluded that gunshot wounds of the cervical esophagus, if treated promptly by suture and drainage, will do well. Thoracic injuries represent a more difficult problem and it is suggested that defunctionalization of the esophagus is the safest procedure, particularly if damage is extensive.

Abscess↗