RESUMEN
We report a case of SMV injury in a critically ill patient. The patient was a 19-year-old woman involved in a motor vehicle collision. Her injuries included grade II splenic and renal lacerations, devascularized and lacerated right and transverse colon, a transected transverse mesocolon, a massive shear injury of her abdominal wall, and two partial SMV transections. At initial damage control laparotomy, the SMV was ligated, the devascularized bowel resected and a temporary abdominal closure applied. At re-operation, a mesocaval shunt using saphenous vein was employed. The shunt failed and the patient required a saphenous vein jump graft. Although visceral vascular injuries are rare, ligation of the SMV in a damage control situation is acceptable. This case study is the first to discuss appropriate treatment when interruption to a patient's collateral visceral venous drainage limits the surgeon's ability to ligate. In these situations, bypass shunts may be successful.
RESUMEN
BACKGROUND: The supine anteroposterior chest radiograph (CXR) is an insensitive test for posttraumatic pneumothoraces (PTXs). Computed tomographic (CT) scanning often detects PTXs that were not diagnosed on CXR (occult PTXs [OPTXs]). The purpose of this study was to define the incidence, predictors, and outcomes for OPTXs after trauma. METHODS: Thoracoabdominal CT scans and corresponding CXRs of all trauma patients entered into a regional database were reviewed. Patients with OPTXs were compared with those with overt, residual, and no PTXs regarding incidence, demographics, associated injuries, early resuscitative predictors, treatment, and outcomes. RESULTS: Paired CXRs and CT scans were available for 338 of 761 (44%) patients (98.5% blunt trauma). One hundred three PTXs were present in 89 patients, 57 (55%) of which were occult; 6 (11%) were seen only on thoracic CT scan. Age, sex, length of stay, and survival were similar between all groups. OPTXs and PTXs were similar in comparative size index and number of images. Subcutaneous emphysema, pulmonary contusion, rib fracture(s), and female sex were independent predictors of OPTXs. Seventeen (35%) patients with OPTXs were ventilated, of whom 13 (76%) underwent thoracostomy. No complications resulted from observation, although 23% of patients with thoracostomy had tube-related complications or required repositioning. CONCLUSION: OPTXs are commonly missed both by CXR and even abdominal CT scanning in seriously injured patients. Basic markers available early in resuscitation are highly predictive for OPTXs and may guide management before CT scanning. Further study of OPTX detection and management is required.
Asunto(s)
Neumotórax/etiología , Traumatismos Torácicos/diagnóstico por imagen , Heridas no Penetrantes/complicaciones , Adulto , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Neumotórax/diagnóstico por imagen , Neumotórax/mortalidad , Sistema de Registros , Resucitación , Factores de Riesgo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagenAsunto(s)
Antihelmínticos/uso terapéutico , Equinococosis Hepática/diagnóstico , Dolor Abdominal/etiología , Adulto , Albendazol/uso terapéutico , Equinococosis Hepática/complicaciones , Equinococosis Hepática/terapia , Enfermedades Endémicas , Femenino , Fiebre/etiología , Humanos , India , Hígado/diagnóstico por imagen , Hígado/patología , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Although posttraumatic pneumothoraces (PTXs) are common and potentially life threatening, the supine chest radiograph (CXR) is an insensitive test for their detection. Computed tomography (CT) often identifies occult pneumothoraces (OPTXs). Previous descriptions of OPTX topography have been poor. Our purpose was to define their distribution and aid in the targeting of thoracic ultrasound. METHODS: Posttraumatic supine CXRs and CTs were reviewed for occult, overt, and residual PTXs. PTXs were compared according to their apical, basal, anterior, lateral, medial, and posterior components. A comparative size index was calculated. RESULTS: Among 761 patients, 338 CT scans revealed 103 PTXs in 89 patients; 55% were OPTXs. OPTXs were apical (57%), basal (41%), anterior (84%), lateral (24%), and medial (27%), with 0% posterior. CONCLUSIONS: CXR missed over half of all PTXs. OPTXs had a greater anterior versus lateral (nearly 4-fold) and both basal and apical versus lateral (2-fold) distribution. OPTXs are often located at easily accessible sonographic windows.