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Portopulmonary hypertension (PoPH) is a well-recognized complication of portal hypertension. This study reports a case of PoPH that was secondarily caused by post-traumatic mesenteric arteriovenous fistula. A 38-year-old man with a history of knife stabbing wounds in the abdomen in 2003 was admitted to the hospital with exertional shortness of breath and a mechanic murmur over the umbilical region. Computed tomography indicated signs of PoPH and mesenteric arteriovenous fistula. Percutaneous catheter-directed embolization was first performed but failed. Subsequently, the patient was successfully treated with fistula resection and partial enterectomy. The patient had been postoperatively followed regularly, and chief symptoms had been alleviated significantly and pulmonary pressure had successfully decreased to normal range. We believe that this is the first case of PoPH caused by mesenteric arteriovenous fistula., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to describe the pattern of solid organ injuries (SOIs) and analyze the characteristics, management and outcomes based on the multiplicity of SOIs., Methods: A retrospective study in a Level 1 trauma center was conducted and included patients admitted with blunt abdominal trauma between 2011 and 2014. Data were analyzed and compared for patients with single versus multiple SOIs., Results: A total of 504 patients with SOIs were identified with a mean age of 28 ± 13 years. The most frequently injured organ was liver (45%) followed by spleen (30%) and kidney (18%). One-fifth of patients had multiple SOIs, of that 87% had two injured organs. Patients with multiple SOIs had higher frequency of head injury and injury severity scores (p < 0.05). The majority of SOIs were treated nonoperatively, whereas operative management was required in a quarter of patients, mostly in patients with multiple SOIs (p = 0.01). Blood transfusion, sepsis and hospital stay were greater in multiple than single SOIs (p < 0.05). The overall mortality was 11% which was comparable between the two groups. In patients with single SOIs, the mortality was significantly higher in those who had pancreatic (28.6%) or hepatic injuries (13%) than the other SOIs., Conclusion: SOIs represent one-tenth of trauma admissions in Qatar. Although liver was the most frequently injured organ, the rate of mortality was higher in pancreatic injury. Patients with multiple SOIs had higher morbidity which required frequent operative management. Further prospective studies are needed to develop management algorithm based on the multiplicity of SOIs.

We present a patient with blunt abdominal trauma with severe acute right limb ischemia and clinical signs of diffuse peritonitis. Computed tomography angiography showed circumferential dissection of the infrarenal aorta with occlusion of the right common iliac artery. We opted for simultaneous abdomen exploration and open repair of injured aorta. Critical weakening of the aortic wall with imminent rupture was identified intraoperatively. Aortotomy cranially from bifurcation showed circumferential intimomedial dissection. The fixation of fragile intimomedial flap of aortic dissection was achieved with reinforcement using an anterior longitudinal ligament. The long aortoiliac arteriotomy was repaired using a great saphenous vein patch. Patient had uneventful postoperative course and was discharged after 7 days. In patients with abdominal polytrauma with peritonitis, and no available endovascular tools, open surgery for circumferential aortic dissection is possible and successful. Described reinforcement of the posterior aortic wall to the anterior longitudinal ligament should be added to the armamentarium of aortic injury treatment.

The aim of this case report is to be aware of occult carotid lesions in thoracic- abdominal trauma because, carotid artery injury consequent to blunt trauma is rare, affecting less than 1% of patients as reported in literature. A 45-years-old female, involved in a traffic accident, arrived to Emergency Room hemodynamically stable, with a Glasgow Coma Scale of 15, complaining abdominal pain, without any neurological signs. She underwent Computed Tomography (CT) scan that showed a complete disruption of left abdominal wall muscles, associated with massive bowel loops herniation. No free air nor other visceral injuries were found. The radiological brain evaluation was negative for neurological injuries. Considering the nature of the trauma, an explorative laparotomy was performed. During the fifth postoperative day, the patient presented neurological side signs with right facial-brachial-crural hemiparesis and expressive aphasia. Head and neck CT scan revealed a lesion of the left common carotid artery with distal embolization of the internal carotid. A left-carotid-axis revascularization procedure and a surgical endarterectomy were immediately performed. Patient was discharged after 20 days without neurological consequences. Physicians should be aware of neck vascular injuries when evaluating patients with multiple trauma, even in neurological asymptomatic patients without seatbelt abrasions of the neck skin., Key Words: Abdominal Hernia, Carotid artery, Seat belt, Surgery.

A 50-year-old man sustained blunt abdominal trauma in a motor vehicle accident. He underwent exploratory laparotomy on the day of trauma, and severe bleeding from the base of the small bowel mesentery was controlled by mass ligation and through-and-through suturing. After transfer to our center, repeat exploratory laparotomy showed ischemic small intestine, ischemic right colon, and severe pancreatic trauma. The severely injured organs were excised including the entire small bowel, pancreas, spleen, stomach, and right hemicolon. The next day, a modified multivisceral transplant was performed including stomach, pancreaticoduodenal complex, and small bowel transplant. Postoperative complications included an intra-abdominal collection that was drained percutaneously with ultrasonographic guidance and severe rejection that was treated with anti-thymocyte globulin. In summary, for select patients who have severe abdominal trauma may be treated with acute multivisceral transplant.

Aim: To determine the correct therapeutic approach to the different grades of liver trauma., Material and Methods: The study is based on a retrospective analysis of treatment outcomes in 56 patients with abdominal trauma admitted over a 9-year period to in the IIIrd Surgical Clinic of the Iasi "Sf. Spiridon" Hospital. It is focused on operative or non-operative management of liver trauma, surgical technique used, morbidity and postoperative mortality. Data were collected from electronic medical records and observation sheets and processed and interpreted using Microsoft Excel statistical functions., Results: In the interval May 26, 2005-April 19, 2013 56 cases of abdominal trauma were recorded, 31 (55.35%) residing in urban areas, and 25 (44.64%) in rural areas. The mean age was 39 years, range 18-83 years old. The male/female ratio was 2.5/1 and the group consisted of 40 (71.42%) male patients and 16 (28.57%) female patients. The causes of abdominal trauma were: car accident in 29 (51%) cases, fall from different heights in 6 (10%) patients, workplace-related accidents in 8 patients (14%) and direct hit injury in 12 patients (12%). In our cohort, 51 (91%) patients with abdominal trauma have been emergency admitted, 3 patients (5%) were transferred from different medical units, and 2 patients (4%) were referred by a specialist doctor. Two or more simultaneous lesions were diagnosed in 53 (96%) cases. Of the 45 patients with traumatic liver injuries diagnosed on admission, 32 (71%) required surgical intervention. In the remaining 13 (29%) patients, the therapeutic management was conservative., Conclusions: Hepatic traumas are often severe, and frequently associated with multiple injuries. The non-operative management is indicated in liver lesions grade I, II and III according to the American Association for the Surgery of Trauma (AAST), if abdominal cavity organs are not injured. Higher grade liver lesions (over IV) in which the hemorrhagic risk persists or reappears require surgical intervention as soon as possible, and according to the type of lesion, the right procedure should be chosen.

Emergency medicine as a medical specialty has to deal with all kind of emergency situations, from medical to post traumatic acute eyents and from new born to the elderly persons, but also with particular situations like explosions. In Romania nowadays these are accidental explosions and rare like frequency, but may be dramatic due to numbers of victims and multisystem injury that may occur. We present a case of a single victim of accidental detonated bomb, a projectile from the Second World War, which unfortunately still may be found in some areas. The management of the case from first call to 112 until the victim is discharge-involves high professional team work. We use these opportunity to make a brief review of the mechanism through the lesions may appear and also to renew the fact that the most impressive lesion may not be the most severe, and we have to examine carefully in order to find the real life threatening injury of the patient.

Massive penetrating trauma by rectal impalement is a very rare form of injury, complicated and potentially lethal. It is even rarer for such injury to result in pelvic, abdominal and thoracic internal damages. We report the case of a 62 year-old man who was admitted in emergency after an aggression with a sharp wooden stake inserted forcibly into his rectum. Clinical examination revealed the blunt extremity of the stake outside the anus and the prominent sharp end reaching his right supraclavicular fossa. Radiographic examination showed the stake extending from the rectum to the right side of the neck.Surgery disclosed penetration through the rectum, retroperitoneum,large bowel mesentery, liver, diaphragm, right lung and right 2nd rib. The patient survived following management by a multidisciplinary surgical team. As similar reported cases are scarce, knowledge of the management of the few cases that have been successfully treated is likely to prepare the emergency teams to act rationally and efficiently in such exceptionally grave circumstances., (Celsius.)

Background: Rib fractures are considered a marker of exposure to significant traumatic energy. In children, because of high elasticity of the chest wall, higher energy levels are necessary for ribs to fracture. The purpose of this study was to analyze patterns of associated injuries in children as compared with adults, all of whom presented with rib fractures., Methods: A retrospective cohort study involving blunt trauma patients with rib fractures registered in the National Trauma Registry was conducted., Results: Of 6,995 trauma victims who were found to suffer from rib fractures, 328 were children and 6,627 were adults. Isolated rib fractures without associated injuries occurred in 19 children (5.8%) and 731 adults (11%). More adults had 4 or more fractured ribs compared with children (P < .001). Children suffered from higher rates of associated brain injuries (P = .003), hemothorax/pneumothorax (P = .006), spleen, and liver injury (P < .001). Mortality rate was 5% in both groups., Conclusions: The incidence of associated head, thoracic, and abdominal solid organ injuries in children was significantly higher than in adults suffering from rib fractures. In spite of a higher Injury Severity Score and incidence of associated injuries, mortality rate was similar. Mortality of rib fracture patients was mostly affected by the presence of extrathoracic injuries., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A 2½ year old girl attended our facility following attack by a tapir at a city zoo. She sustained multiple injuries including a forearm laceration and multiple perforating wounds to her abdominal wall. She had several procedures, including bowel resection, performed under the care of the General Paediatric Surgery and Plastic Surgery teams and was treated with a course of IV antibiotics. She recovered well and to date has suffered no long-term adverse outcome.

Background: Classically, seat belt syndrome appears with seat belt marks on the body, bowel perforations, and lumbar spine fractures. However the symptoms are not limited to those previously mentioned, and organ damage can vary greatly., Case Report: A 34-year-old female passenger, was admitted to our hospital after a motor vehicle crash. The physical examination revealed an ecchymosis across the chest, a transverse abdominal abrasion, and fractures of the left humerus, the left femur, and the right tibia. The laparotomy revealed multiple jejunal perforations, such as a seromuscular tear of the hepatic and splenic flexure of the colon and a defect of the abdominal wall. The primary suture of jejunum, resection with end to end anastomosis of jejunum, suture of a seromuscular tear of the colon, and primary repair of the abdominal wall defect procedures were performed. On the fifth day, the patient underwent osteosynthesis., Conclusion: The abdominal pain in the polytraumatized patients with seat belt syndrome may be dominated by the pain caused by extra-abdominal injuries. The presence of a seat belt mark across the abdomen increases suspicion of abdominal injuries.

Unlabelled: Trauma is the principal cause of mortality among the population under 40 years. The aim of our study was to compare predictive trauma scores and demonstrate their utility in the evaluation of the quality of care in polytrauma., Material and Methods: A retrospective study was performed between 2000-2011 including polytrauma patients with abdominal lesions and pelvic fracture who under went emergency laparotomy. We calculated ISS, GCS, RTS,TRISS, ASCOT trauma scores and W score for evaluation of treatment quality., Results: We obtained the necessary data to calculate the predictive scores in 38 cases. Comparing the scores of the survivals and non-survivals we noted the following regarding mortality predictive scores: GCS 13.74 vs. 6.13 (p 0.0001),ISS 28.52 vs. 35 (p=0.0169), RTS 6.96 vs. 3.07 (p 0.0001),TRISS 84.67% vs. 28.7% (p 0.0001), ASCOT 10.34% vs.64.32% (p 0.0001). The W score in TRISS and ASCOT methodology was -2.05 (p=0.7997) and -7.81 (p=0.336),respectively. There was no statistically significant difference between actual and predicted mortality, the former being 39.47%., Conclusion: We did not observe differences between the two methodologies TRISS and ASCOT in mortality prediction (p=0.5401). Both of them can be used to predict polytrauma patient evolution. The W score is useful in treatment quality assessment., (Celsius.)

Background: Terrorist explosions occurring in varying settings have been shown to lead to significantly different injury patterns among the victims, with more severe injuries generally arising in confined space attacks. Increasing numbers of terrorist attacks have been targeted at civilian buses, yet most studies focus on events in which the bomb was detonated within the bus. This study focuses on the injury patterns and hospital utilisation among casualties from explosive terrorist bus attacks with the bomb detonated either within a bus or adjacent to a bus., Methods: All patients hospitalised at six level I trauma centres and four large regional trauma centres following terrorist explosions that occurred in and adjacent to buses in Israel between November 2000 and August 2004 were reviewed. Injury severity scores (ISS) were used to assess severity. Hospital utilisation data included length of hospital stay, surgical procedures performed, and intensive care unit (ICU) admission., Results: The study included 262 victims of 22 terrorist attacks targeted at civilian bus passengers and drivers; 171 victims were injured by an explosion within a bus (IB), and 91 were injured by an explosion adjacent to a bus (AB). Significant differences were noted between the groups, with the IB population having higher ISS scores, more primary blast injury, more urgent surgical procedures performed, and greater ICU utilisation. Both groups had percentages of nearly 20% for burn injury, had high percentages of injuries to the head/neck, and high percentages of surgical wound and burn care., Conclusions: Explosive terrorist attacks detonated within a bus generate more severe injuries among the casualties and require more urgent surgical and intensive level care than attacks occurring adjacent to a bus. The comparison and description of the outcomes to these terrorist attacks should aid in the preparation and response to such devastating events., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Blunt abdominal aortic injury (BAAI) is very rare, and current literature is limited to case series of single-center experience. Through an analysis of the National Trauma Data Bank, the largest aggregation of United States trauma registry data, our aim was to characterize the associated injury pattern, contemporary management, and in-hospital outcomes of patients with BAAI., Methods: We used a nested case-control design. The overall cohort consisted of adult patients (age ≥ 16 years) severely injured (Injury Severity Score ≥ 16) after blunt trauma who were treated at a level 1 or 2 trauma center in years 2007 to 2009. Cases were patients with BAAI and were frequency-matched by age group and mechanism to randomly selected controls at a one-to-five ratio. Multivariable matched analysis (conditional logistic regression) was used to derive adjusted measures of association between BAAI and adjacent arterial, intra-abdominal, and bony injuries., Results: We identified 436 patients with BAAI from 180 centers. The mean Injury Severity Score was 35 ± 14, and most patients were injured in motor vehicle crashes (84%). Multivariable analysis showed injury to the thoracic aorta, renal and iliac artery, small bowel, colon, liver, pancreas, and kidney, as well as lumbar spine fractures were independently associated with BAAI. A total of 394 patients (90%) were managed nonoperatively, and 42 (10%) underwent repair. Of these 42 patients, 29 (69%) underwent endovascular repair, with 11 patients undergoing open aortic repair and two extra-anatomic bypasses. Median time from admission to repair was 1 day (interquartile range, 1-2 days). Overall mortality was 29%. A total of 271 (69%) patients managed nonoperatively survived to hospital discharge., Conclusions: The index of suspicion for BAAI should be raised in severely injured patients by the presence of injuries to the lumbar spine, bowel, retroperitoneal organs, and adjacent major arteries. Although endovascular repair is the most common intervention, most patients are managed nonoperatively and survive to hospital discharge., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

We report here a fetus, who was delivered via cesarean section in 32th gestational week from a 37-year-old mother and sustained multiple gunshots. Post-natal evaluation revealed eight entry-exit holes and the baby was transferred to our clinic.Upon admission, peripheral pulses were nonpalpable, appropriate fluid administration and blood transfusion were conducted and further examinations revealed bladder perforation. Bladder was repaired over a suprapubic catheter and bullet holes were primarily sutured. Left foot drop was observed on follow up and the patient was discharged with no further complication. Although the maternal and the fetal morbidity and mortality rates are high in intrauterine gunshot wounds, appropriate management may provide survival as seen in our case.

Traumatic diaphragmatic injuries are uncommon in children. Chance fractures are typical in adults who had motor vehicle accidents but infrequent in children. The seat belt syndrome is characterized by a spectrum of injuries caused by the compression of the abdomen by the seat belt. It can affect the abdominal wall, hollow or solid organs, and the spine, but the association between diaphragmatic rupture and Chance fracture is extremely rare. We describe the case of a child who was involved in a car accident and who presented with multiple traumas; liver and lung injuries were first detected, and the patient was managed accordingly. During the hospital stay, a right diaphragmatic avulsion and a Chance fracture, which were initially missed, were diagnosed and treated successfully. The relevance of this case lies in the low incidence of the diaphragmatic rupture and the Chance fracture in children along with their exceptional association and in the diagnosis, which might be especially difficult in the acute setting.

The triad of seatbelt-related severe abdominal wall disruption, hollow viscus injury, and distal abdominal aortic injury after a motor vehicle collision is uncommon. We present a small case series involving those three clinical features with the goal of preventing a future missed diagnosis of the distal abdominal aortic injury in particular.

The aim of the present study was to assess the prognostic significance of thoracic and abdominal trauma in severely injured patients. A retrospective analysis was performed based on data from the period from March 1 2006 to December 31 2007, taken from the Trauma Registry of the University Hospital "SantAndrea" in Rome. A total of 844 trauma patients were entered in a database created for this purpose, and only patients with an Injury Severity Score (ISS) > 15, (163 patients, 19.3%), were selected for the present study. These patients were divided into 2 groups: Group A (103 patients, 63.2%), consisting of patients with at least one thoracic injury, and Group B (46 patients, 28.2%) consisting of patients with concomitant thoracic and abdominal injuries. The impact of thoracic and abdominal trauma was studied by analyzing mortality and morbidity, in relation to patient age, cause and dynamics of trauma, length of hospital stay, and both ISS and New ISS (NISS). In a vast majority of cases, the cause of trauma was a road accident (126 patients, 77.3%). The mean age of patients with ISS > 15 was 45.2 +/- 19.3 years. The mean ISS and NISS were 25.7 +/- 10.5 and of 31.4 +/- 13.1 respectively. The overall morbidity and mortality rates were 18.4% (30 patients) and 28.8% (47 patients) respectively. In Group A the mortality rate was 23.3% (24 patients) and the morbidity rate was 33.9% (35 patients). In Group B mortality and morbidity rates were 369% (17 patients) and 43.5% (20 patients) respectively. It was shown that the presence of both thoracic and abdominal injuries significantly increases the risk of mortality and morbidity. In patients with predominantly thoracic injuries, NISS proved to be the more reliable score, while ISS appeared to be more accurate in evaluating patients with injuries affecting more than one region of the body.

Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

Background: The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks., Objective: To characterize the abdominal injuries inflicted by terrorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma., Methods: Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87)., Results: Median injury severity score in the blast group was significantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P < 0.0001). Injury to multiple body regions (> or = 3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P < 0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P < 0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%)., Conclusions: Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings.

Unlabelled: Polytraumatisms have always been a concern in human history, their number increasing especially during wars. Their forecast depends on many factors, starting from means of transportation, first aid's promptitude, technical endowment which evolved a lot within the years. Amongst the thoracal-abdominal, the cranial-cerebral and vertebral-medullary injuries, the cranial-cerebral and the abdominal injuries are the most severe ones. We hereby present the evaluation scales according to various criteria (seriousness, prognosis, clinical valutation). In the case of abdominal and neurosurgical injuries the symptomatology can be modified by addition or defalcation, which may cause diagnostic errors with consequences upon morbidity and mortality., Material and Method: We hereby present a study accomplished within three departments: Piatra Neamţ Emergency Hospital, Piatra Neamţ Coronary Office and Iaşi Neurosurgery Clinic, and we find the injury associations in polytrauma cases., Results: We notice a prevalence of the male sex, of the country people, of traffic accidents, of the active age 20-60 years old. The association within abdominal trauma and neurological injuries is of 16.97% in Iaşi Neurosurgery Clinic. After being solved, the neurological injuries are sent to surgery departments, for solution or surveillance., Conclusion: In order to optimize the medical assistance for traumatized persons we hereby recommend a polytrauma centre establishment.

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.

Background: The difficulties in diagnosing traumatic diaphragmatic rupture (TDR) at the first admission are the most common causes of morbidity and mortality. The purpose of this study was to review our experience with the management of TDR in order to identify the factors contributing to diagnostic delay and associated morbidity and mortality., Methods: Fourteen patients with TDR were treated in our hospital between January 2000 and June 2005. They have been investigated retrospectively., Results: The study identified 9 men (64 %) and 5 women (36 %), with ages ranging from 19 to 65 years (mean 35.3 years). Rupture of the diaphragm was left-sided in 10 (71 %) and right-sided in 4 (29 %) of the patients. Blunt trauma accounted for the injuries of 11 patients (79 %). Early diagnosis was obtained in 9 patients (64 %). The diagnosis was established preoperatively in 8 patients (57 %), and intraoperatively in 4 (29 %). The diagnosis was missed in 2 (14 %) patients in the first operation. Multiple associated injuries were observed in 12 patients (85 %). Postoperative complications were encountered in five patients (35 %), and the overall mortality was 7 %., Conclusions: Diaphragmatic rupture should be suspected in all blunt or penetrating traumas of the thorax and abdomen, and the presence of such an injury should be excluded before terminating the exploratory procedure.

The authors present the case of a 21-years-old patient who was admitted in the hospital with a severe abdominal gunshot wound and hemorrhagic shock. Because of the gravity of the external bleeding and the severity of his general status he was admitted directly to the surgery room. The decision of surgical treatment was taken from the first look, so all the diagnostic maneuvers were taken in the surgery room at the same time with the preparations for general anesthesia and surgery, except for the clinical exam and preservation of blood and urine. The duration of the surgical operation was relatively short, almost 2 hours, compared with the visceral lesions identified and treated. The recovery was amazingly rapid, with no significant complications, the patient being discharged from the hospital after 17 days. This case has some particularities which can be discussed: immediate surgery is the only way to give a chance of survival in these kinds of situations; never loose time with other investigations; single gunshot wound of the abdomen determined 4 visceral lesions, every one of them being very severe; the patient had a very short period of recovery.

Purpose: The goal of this retrospective study was to evaluate the spectrum of abdominal injuries and the reliability of computed tomography-based diagnosis in patients after polytrauma., Material and Methods: CT findings and clinical reports for 177 patients after polytrauma were evaluated with regard to abdominal injuries. Clinical patient reports at the time of discharge from the hospital were utilized as the standard of reference. Abdominal injuries resulting from an accident, frequent additional traumas and following therapeutic procedures were recorded. In the case of discrepancies in the reports, the CT scans were viewed retrospectively., Results: In 30 out of 177 patients, 42 abdominal injuries were detected. 69 % of the injuries were caused by traffic accidents while 31 % resulted from falls. Liver and spleen injuries were the most common. 50 % of the cases were treated surgically, and the other half of the cases underwent non-surgical conservative therapy. Massive chest traumas, pelvic injuries, cerebral traumas and injuries to extremities were commonly associated with abdominal injuries. Evaluation of the discrepancies in the clinical reports showed that injury to the pancreas and the small intestine were not successfully detected on CT, thus resulting in a false negative diagnosis. Early stages of organ parenchyma laceration were also initially misdiagnosed on CT., Conclusion: Contrast-enhanced whole-body MSCT is a reliable and rapid method for diagnosing abdominal injuries in patients after polytrauma. Only very few patterns of injury are not detected on CT. The appearance of fluid collection in the abdomen is an indicator of possible parenchyma injury and requires further evaluation in cases of clinically suspected organ trauma.

Background: In our region we have noticed an increasing number of cyclists and consequently a rise in bicycle-related accidents in recent years. A large number of our polytraumatized patients are victims of bicycle-related accidents., Material and Methods: Retrospectively we analyzed the data of our polytraumatized patients recorded between May 2003 and June 2004 for bicycle-related injuries. Of 153 polytraumatized patients treated in our emergency room 32 were cyclists (21%). The average age of our polytraumatized cyclist was 42 years, and the male-to-female ratio was 1:1., Results: The median score on the Glasgow Coma Scale (GCS) after the accident was 8 (min. 3, max. 15), the median Injury Severity Score (ISS) was 24 (min. 18, max. 41), and the median Polytrauma Score (PTS) was 23 (min. 14, max. 51). A total of 30 patients (94%) suffered a head injury; in 28 patients (88%) the head injury was the leading diagnosis. The median score on the Abbreviated Injury Scale (AIS) Head was 4 (min. 1, max. 5), the AIS Thorax 3 (min. 2, max. 4), and the AIS Extremities 3 (min, 2, max. 5). Our data were also compared with the official injury statistics of the region and the current literature., Conclusion: The most frequent and most severe injury was the head injury (94%). Of the 32 polytraumatized cyclists 30 did not wear a helmet. Successful prevention could possibly be practiced if all cyclists wear helmets.

We present our experience with a management of seat-belt syndrome in three children and draw particular attention to the severity of two-point fixation seat-belt injuries after a motor vehicle accident with 5 passengers whose vehicle was struck head-on by an oncoming vehicle. The parents were sitting in front, Adeline had a 2-point lap seat-belt, the 2 other children had 3-point seat-belts. The parents both had humerus fractures. The 4-year-old brother suffered a cervical and abdominal trauma with renal and splenic contusions and intestinal perforations. Adeline suffered multiple injuries, notably to the head, spine and abdominal viscera with erosions at the site of lap-seat-belt contact. The spinal injury was an L2 angular Chance fracture associated with paraplegia on the 7th day. Operative findings included a transverse tear of the left rectus abdominus muscle, an incomplete transection of the stomach and perforation of the ileum. The injuries were ultimately fatal. Given associated abdominal pain, skin erosions at the site of seatbelt contact, spinal fracture, and rectal muscle disruption apparent on emergency laparotomy, early diagnosis is important for better prognosis.

Purpose: The goal of the current study was to evaluate the risk of intraabdominal injury in children who sustained spinal fractures in a motor vehicle collision (MVC)., Methods: Between 1980 and 1999, 48 patients, 24 girls and 24 boys, with a mean age of 12.8 years (range, 4 to 17) were reviewed. Twenty-nine were rear seat passengers, 12 front seat, and 7 unknown. Fifty-eight percent wore a seat belt. Thirty fractures involved the lumbar spine, 12 the thoracic, and 6 combined. Computed tomography (CT) scan, abdominal ultrasound, and peritoneal lavage were used to screen for abdominal injuries., Results: Twenty-two of 48 patients had an intraabdominal injury. Eighteen (38%) required an early (<24 hours; n = 12) or delayed (n = 6) therapeutic laparotomy. Fourteen patients were rear seat passengers, 15 wore a seat belt, and 13 had an abdominal wall ecchymoses (AWE). They were 17 lumbar fractures (13 Chance) and one thoracic. The most common findings at laparotomy were hollow viscus injury (n = 12), mesenteric tear (n = 9), and solid organ injury (n = 8). Seventy-two percent of patients presenting with a lumbar fracture and AWE needed a therapeutic laparotomy. The overall survival rate was 98% with only 1 death. The mean hospital stay was 22.4 days. In this study, 38% of patients presenting with a spinal fracture required laparotomy, 68% of whom had simultaneous lumbar fracture and AWE., Conclusion: In light of these results, the authors propose that laparoscopy or laparotomy should be strongly considered in patients sustaining lumbar fracture and AWE after MVC. J Pediatr Surg 36:760-762., (Copyright 2001 by W.B. Saunders Company)

A case of vehicle accident trauma to the abdominal aorta in a patient wearing a lap-type seat belt is presented, together with its diagnosis and management. The role of the radiologist is emphasized.

"Pale sink" trauma in 16 years old boy has been described as a cause of multi-organ injuries.

Background: The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis., Methods: A 9-year trauma registry review of all patients with HVI., Results: A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05)., Conclusion: HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.

Last years in the country gace rise to the problem of treatment of fire-arm's wounds in civil population. The results of treatment of victims with firearm thoracoabdominal wounds have evidenced unprepareness of surgeons for rendering specialized aid in conditions of "military-urban" surgery. The study performed by the authors has shown that there are substantial and principal differences between many postulates of war-field surgery and "military-urban" surgery. It consists in early hospitalization of victims with combined thoraco-abdominal injuries, prevalence of bullet wounds over fire-mine explosive injuries which have an effect on the extent of surgical intervention, results of treatment and development of complications. The proposed treatment modalities in victims with combined penetrated thoracoabdominal injuries in great measure may contribute to optimization of surgical aid in conditions of "military-urban" surgery.

An experience with surgical treatment of 136 patients with left-side thoracoabdominal knife wounds has shown that all the patients can be divided into two groups: transpleural wounds (111 cases or 81.7%) and extrapleural wounds (25 cases or 18.3%). Symptoms of extrapleural wounds (medial and lateral) are described. Injuries to organs of the abdominal cavity were shown to depend on the localization of the diaphragm wound. It was found that in patients with wounds to the posterior cupula there were only injuries of organs fixed in the subdiaphragmatic space.

A statewide experience with pediatric abdominal visceral injury in restrained automobile passengers was compiled from the trauma registries of two academic institutions. Retrospective analysis of motor vehicle passenger injuries from 1987 to 1991 included age, sex, mechanism of injury, prehospital care, type of injury, therapeutic interventions, complications, and ultimate outcome. The records of over 2,000 patients evaluated for blunt trauma were reviewed, with 42 children fulfilling the following inclusion criteria: 15 years of age or younger, restrained in an automobile at the time of the accident, and diagnosed with an abdominal injury. Of the 42 patients studied, there were 20 boys and 22 girls; ages ranged from 2 months to 15 years (mean, 7.02 years). Six of 42 patients (14%) required extrication from the vehicle at the scene. Nineteen of 42 patients (45%) sustained belt-related abdominal wall bruising or erythema. The specific blunt visceral injuries noted were as follows: splenic 5, hepatic 5, bowel 6, renal 3, combined 6 (stomach, diaphragm, pancreas, or retroperitoneum). Twenty-three children (55%) had abdominal visceral injuries without external seat belt marks. Operative intervention was necessary in seven patients. A delay in diagnosing visceral injury occurred in 4 of 42 (10%) cases. One patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay ranged from 1 to 45 days. Complications occurred in 4 (10%) of patients. There were two deaths due to injuries. Hollow and solid visceral injuries can occur in belted pediatric passengers during vehicular accidents. Both are a source of significant morbidity, and the patient should be evaluated carefully.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a case of associated injuries (thoracoabdominal trauma with multiple rib and sternum fractures, perforation of the small intestine, abdominal cutaneous ecchymosis) caused by a seat belt, and describe the possible seat-belt mechanisms of lesion in road accidents. Some clinical aspects are discussed; in particular the diagnostic problems concerning a seat-belt syndrome as well as the limits of effectiveness in the use of belts.

Loadings induced by deploying currently representative air bags were studied with driver surrogates (anesthetized swine) leaning against the system during inflation. Torso injury mechanisms were studied in a physiologic model, supported against a static steering wheel-mounted air bag system. Severe and extensive chest and abdominal injuries to the swine were observed in the tests. Loading caused by air bag deployment can occur in either of two phases. The first phase represents the initial punch out of the bag from the module; the second phase represents the membrane force of the inflating bag. Statistical analysis indicated that punch out induced injury because of the high rate of loading to the surrogate body region in direct contact with the air bag module. Membrane forces induced injury by high compression over a larger area. Punch-out loading might be reduced by allowing the bag to escape from other parts of the container not in contact with the driver during deployment. Loading by the inflating bag might be reduced by using a compliant steering system to support the module. The amount and rate of generated gas had only marginal effect on the cumulative injury. Even an inflator with inadequate gas output to protect a properly seated occupant had sufficient energy to induce severe injuries in a surrogate in contact with the inflating module. Analysis of the field relevance of the results must consider not only the injury potential given that a driver is in direct contact with the air bag module at the time of deployment, but also the expected field frequency of such an event. Analysis of the field relevance of the results must also consider the correlation of the laboratory test environment with real-world exposure.

415 spinal fractures were analysed retrospectively. A simultaneous occurrence of vertebral fracture and abdominal trauma was found in 14 patients (3.4%). The mechanism of injury was a fall from a considerable height in 9 cases, a car accident in 3 and a motorcycle accident in 2. Isolated fractures of the transverse processes and rotational injuries of the spine were found to be associated particularly frequently with an abdominal trauma (3 of 14 isolated fractures of the transverse processes = 22%, 5 of 61 rotational injuries = 8.2%), while compression injuries only showed such a simultaneous abdominal injury in 2% of the 300 fractures of this type. We never encountered the combination of distraction injury/abdominal trauma. This is probably because two-point lap-type seat belts are only rarely used in our country. In 2 patients with rotational injuries neurological deficits were observed. The abdominal injuries encountered in our patients were: massive concussion of the kidney (6 cases), rupture of the spleen (3 cases), rupture of the liver (2 cases), rupture of the mesocolon (2 cases), rupture of the caecum (1 case), rupture of a pre-existent aneurysm of the aorta (1 case), rupture of a renal artery (1 case), massive retroperitoneal haematoma (1 case). Other injuries were present in 12 of the 14 patients: 3 craniocerebral injuries, 7 fractures of the long bones, 6 injuries to the thorax and 3 to the pelvis. In conclusion, a simultaneous finding of vertebral fracture and abdominal trauma is rare in our patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The case of a 9 year old male child with Down syndrome and multiple injuries including splenic injury, who was incidentally found to have bilateral Morgagni hernia is presented. Aspects of pre-operative diagnosis and management are discussed.