Trauma Surgery - Science topic

Accidents involving motorcycles are responsible for over 50% of open fractures of the tibia and can be associated with other lesions and the victims, in the vast majority, are youth and young adult (Brazil epidemiological data). What preventive measures could be taken to reduce this type of accident?

In our practice, an estimated bullet trajectory is almost always used as a guide to intro-abdominal injuries during management of abdominal gunshot patients. While it seems logical to expect that the bullet would have damaged all structures that came in its path, what are the global practices of using an estimated trajectory when in the present era there are increasing trends of selective non operative management of gunshot patients based on objective clinical and diagnostic findings?

A young patient (28 years) presented to our casualty with gunshot right chest within 1 hour of injury with stable vitals except tachycardia. The entry wound was in the right lower chest in mid-clavicular line tracting towards right side of abdomen. The bullet was found to lie in the pelvis on x-ray abdomen erect and lateral views but there was no pneumoperitoneum. Patient had right pneumothorax on x-ray of chest. Due to the mechanism of injury, direction of bullet tract and location of bullet, bowel injury and diaphragmatic injury was presumed; and patient underwent laparotomy within 3 hours of injury but per-operatively no bowel, solid organ injury or hemoperitoneum was found. The bullet could be palpated retroperitoneally against the right pubic bone. Limited retroperitoneal exploration on right side which revealed no retroperioteal injury or hematoma. No diaphragmatic rent was found. How this location of bullet can be explained on the basis of above findings? Patient was discharged after 6 days without any complications.

20/f with loss of vision for 4 year in left eye. Cataractouts lens and 360 degree posterior synaechie. No h/o ocular trauma and surgery. Ultrasound so this high echoiec calcified mass without central halo in front of optic disc. What it could be? How should we proceed?

If i am doing a prospective randomised study on fracture pt and i have selected 90 patients and i have to divide them into 3 groups. But the patients will be recruited as they will come to the clinci over a period of time. How will i ensure randomisation and equal number of 30 in 3 groups?

fracture pt will be divided into 3 groups

Inflammatory mediators promote insulin resistance, suggesting perhaps that critical care patients may exhibit hyperinsulinemia. However, I have great difficulty finding an article referring to serum insulin levels (there is an overabundance of publications on hyperglycaemia and insulin resistance but not insulin).

I would very much appreciate it if anyone can refer me to a manuscript making reference on insulin levels in any severe inflammatory setting (burns, sepsis, trauma, and surgery… any context where a strong inflammatory response is solicited).

Note: hyperglycaemia is often treated with intensive insulin therapy –it would be super if the study refer to untreated patients.

A 35 year old female presented to the outpatient ENT clinic in AL-Hussein teaching hospital/Samawah city with painless swelling over the posterior aspect of the right auricle 2 years ago, the swelling is gradually increasing in size. There is no history of previous trauma or surgery.

   The mass is non tender, oval in shape, measured 5ₓ 3 cm. in dimeters, freely mobile, fluctuant and the skin overlying it is warm on touch and there is an increased in its vascularity. There is no scar and no changes over the skin surrounding the swelling. The swelling is neither pulsatile nor compressible.

   The mass was excised under general anaesthesia and sent for histopathological examination and we are waiting for the result of the pathological evaluation. Grossly the mass is an oval in shape, 5ₓ 3 cm in dimeters, when excise part of it, its cavity  contains a blood with a thick wall but the cavity contains no hair.

What is the differential diagnosis of this swelling?

Thank you in advance for your valuable response.

Best regards

Raid

Ultrasound has been used for different functions, what is its role in the diagnosis, evaluation and evolution of intra-abdominal hypertension?

What are the current indications for the use of Diagnostic Peritoneal Lavage (DPL) in abdominal trauma patients?

ATLS 

We had a 23 years old who had a gunshot injury in the right 3rd space 2 hours ago. A right chest tube was inserted and it drained 250 cc blood with complete lung expansion. ECG and cardiac enzymes were normal. Echo was performed which showed a mild hemopericardium with no tamponade. CT Chest showed a right sided lung contusion with mild pericardial collection and the bullet in the subcaribal region. He was monitored in ICU on IV fluids, Tramal 50 mg TID and perfalgan 1gm QID. Patient was fully conscious initially and remained same for 8 hours then started to be agitated. He was ventilated electively due to CO2 retension 9 hours after trauma because of respiratory acidosis. F UP ECHO showed mild rim of pericardial effusion with no tamponade. F UP CT showed the same CT findings presented earlier. Patient was kept ventilated for 3 days on no inotropes. Suddenly he became severely agiatated again on ventilator with good blood gases. He arrested for 40 minutes despite good CPR. An urgent subxiphoid drainage window was performed and drained only 50cc. ECG regained again for 2-3 minutes then arrested again and he was declared dead. Where was the problem? What we missed in the management? What are the possible causes of death?

Mid aged man presents with 1.5m steel rod penetrating through the skull up to the genitals and beyond attracting all major specialities in one surgical table~ Neuro-Stomatology- ENT-Thoracic-Cardio-General-Uro-Ortho-

If i encounter a case of gunshot with a foreign body in the chest  and the patient is stale after chest tube drainage shall i remove the bullet?

Any specific treatments to avoid other than stressing the plantarflexors until 6 weeks?  Everything I have read has said to focus on ROM to patient tolerance and to WB in a boot until the 6 week mark.  I am currently following the protocol for the Strayer method listed in this attachment.  Any input would be helpful, thanks.

ATLS(R)'s providor manual states its at the junction of medial and middle thirds of clavicle so does medscape.

whereas the just in time video for the same program states its the junction of lateral 1/3 and medial 2/3 of clavicle.

Does anyone knows any new guidelines ?

The continued mechanical stress caused by the chronic presence of a relatively high fill volume is at least a cause of interstitial remodeling and therefore contributes to the burden of inflammation.

In each exchange, the tissues bordering the peritoneal cavity are exposed to a mechanical stress of 2 kg. Do the mass to calculate the mechanical stress over the peritoneum in one year! 

Male patient, 46y motorcycle accident. Cardiac arrest at the scene for 5 min. Whole body CT with thoracic trauma only. Flail chest from 2nd to 7th left ribs(CT attached). Eco: normal. 5th day after trauma still in the ventilator. Fever from a probable pulmonar infection. Had an air leak until day 3, now there is no air leak. Would you perform an titanium plate (I'd use the MatrixRib system) fixation procedure in this case? Can we put those plates in patients with systemic infection?

We recently have evaluated a 60 years old male who was victim of 

If you prefer operative treatment, do you use plating, external fixation or primary arthrodesis? Is there an indication for non-operative care?

It was a mid shaft open clavicle fracture associated with scapular neck fracture occurred after attack with an ax or similar tool. The patient also had a serious head injury. At 3 a.m., I intramedullary placed a 20cm long Schantz pin. Fortunately, the main neuro-vascular structures and lung were intact.

There are only few articles related to this topic.

Recently a paper published by Seamon raised the question of performing ED Thoracotomies in Traumatic Cardiac arrest cases. Do you think it is worth it in non-penetrating trauma cases?

Recently an American Society of Anesthesia launched a guideline where the use of ultrasound to place a central line is mandatory.