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BACKGROUND: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care. METHODS: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality. RESULTS: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides. CONCLUSION: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach.

Assuntos

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PURPOSE: The abuse of cocaine and its derivatives presents a likely risk factor for injury. Trauma incurred by cocaine and derivative abusers may be more severe than that incurred by non-users. OBJECTIVES: To ascertain the presence of cocaine and its derivatives in trauma patients and to correlate RTS (Revised Trauma Score) and ISS (Injury Severity Score) with the presence of cocaine and its derivatives in blood and urine samples. METHODS: All trauma victims treated in an emergency unit between November 11, 2012 and September 15, 2013 were included in the study. Blood and urine samples were collected on admission to hospital. RTS and ISS scores were then compared with the presence or absence of cocaine and its derivatives in the samples. The associations between RTS < 7.84 and ISS > 16 and the independent variables were evaluated by the gross odds ratio values, determined by univariate logistic regression. Multivariate analysis was performed using multivariate logistic regression. RESULTS: Of 453 patients (83.7% male) included in the study, 28.6% presented ISS > 16 and 33.6% presented RTS < 7.84. A total of 435 samples were collected, and 86 (19.8%) provided positive samples for cocaine, 48 (11%) for crack and 69 (15.9%) for cocaethylene. Compared to other patients, drug users showed a greater probability of RTS < 7.84 (2.18 times greater) and a greater probability of ISS > 16 (1.76 times greater). CONCLUSION: For the trauma patients included in our study, the use of cocaine and its derivatives was shown to be associated with more severe traumas, as demonstrated by their RTS and ISS scores.

Assuntos

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Demographics and mechanisms were analyzed in prospectively maintained level one trauma center database 1990-2012. Among 2,693 trauma laparotomies, 113 (4.1%) presented bladder lesions; 51.3% with penetrating injuries (n = 58); 41.3% (n = 24) with rectal injuries, males corresponding to 95.8%, mean age 29.8 years; 79.1% with gunshot wounds and 20.9% with impalement; 91.6% arriving the emergence room awake (Glasgow 14-15), hemodynamically stable (average systolic blood pressure 119.5 mmHg); 95.8% with macroscopic hematuria; and 100% with penetrating stigmata. Physical exam was not sensitive for rectal injuries, showing only 25% positivity in patients. While 60% of intraperitoneal bladder injuries were surgically repaired, extraperitoneal ones were mainly repaired using Foley catheter alone (87.6%). Rectal injuries, intraperitoneal in 66.6% of the cases and AAST-OIS grade II in 45.8%, were treated with primary suture plus protective colostomy; 8.3% were sigmoid injuries, and 70.8% of all injuries had a minimum stool spillage. Mean injury severity score was 19; mean length of stay 10 days; 20% of complications with no death. Concomitant rectal injuries were not a determinant prognosis factor. Penetrating bladder injuries are highly associated with rectal injuries (41.3%). Heme-negative rectal examination should not preclude proctoscopy and eventually rectal surgical exploration (only 25% sensitivity).

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Bile duct injury is a known complication of cholecystectomy. While minor injuries can be treated endoscopically, successful endoscopic management of complete ligation of the common hepatic duct (CHD) has not been described. Our aim was to report a novel technique for endoscopic recanalization of accidently ligated CHD. We demonstrated a 75 year old woman presented with a small bile leak and complete ligation of the CHD after open cholecystectomy subjected to successful biliary endoscopic recanalization. Cholangiogram demonstrated resolution of the bile leak and minimal residual narrowing of the CHD. Endoscopic intervention following biliary needle puncture access may avoid surgery in patients with CHD ligation or complex stenosis.

Assuntos