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Revista Do Colegio Brasileiro de... Oct 2018to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the...
OBJECTIVE
to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution.
METHODS
an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence.
RESULTS
two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases.
CONCLUSION
distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.
Topics: Adult; Amputation, Surgical; Arteries; Brazil; Female; Health Services Accessibility; Humans; Incidence; Male; Middle Aged; Retrospective Studies; Risk Factors; Sex Distribution; Vascular System Injuries; Veins
PubMed: 30304097
DOI: 10.1590/0100-6991e-20181844 -
Scientific Reports Dec 2020The dural venous sinuses play an integral role in draining venous blood from the cranial cavity. As a result of the sinuses anatomical location, they are of significant...
The dural venous sinuses play an integral role in draining venous blood from the cranial cavity. As a result of the sinuses anatomical location, they are of significant importance when evaluating the mechanopathology of traumatic brain injury (TBI). Despite the importance of the dural venous sinuses in normal neurophysiology, no mechanical analyses have been conducted on the tissues. In this study, we conduct mechanical and structural analysis on porcine dural venous sinus tissue to help elucidate the tissues' function in healthy and diseased conditions. With longitudinal elastic moduli values ranging from 33 to 58 MPa, we demonstrate that the sinuses exhibit higher mechanical stiffness than that of native dural tissue, which may be of interest to the field of TBI modelling. Furthermore, by employing histological staining and a colour deconvolution protocol, we show that the sinuses have a collagen-dominant extracellular matrix, with collagen area fractions ranging from 84 to 94%, which likely explains the tissue's large mechanical stiffness. In summary, we provide the first investigation of the dural venous sinus mechanical behaviour with accompanying structural analysis, which may aid in understanding TBI mechanopathology.
Topics: Animals; Brain Injuries, Traumatic; Cerebral Veins; Comorbidity; Cranial Sinuses; Disease Models, Animal; Dura Mater; Hematoma, Subdural, Acute; Swine; Vascular Stiffness
PubMed: 33303894
DOI: 10.1038/s41598-020-78694-4 -
CEN Case Reports May 2021A 78-year-old woman who sustained traumatic liver injury with hemorrhagic shock was hospitalized. She was admitted to the ICU after blood transfusion and emergent...
A 78-year-old woman who sustained traumatic liver injury with hemorrhagic shock was hospitalized. She was admitted to the ICU after blood transfusion and emergent angiography. AKI was observed on the following day. Blood transfusion was continued because initial assessment was prerenal AKI due to hypovolemia. Despite transfusion of blood products and administration of diuretics, aggravated renal dysfunction, and low urine output continued, resulting in respiratory failure due to pulmonary edema. Renal venous congestion was suspected as the primary cause of AKI, since IVC compression from a hematoma with IVC injury was observed on CT imaging captured on admission, and renal Doppler ultrasonography demonstrated an intermittent biphasic pattern of renal venous flow. It was finally concluded that renal venous congestion resulted from IVC compression, since urine output increased remarkably after RRT without additional diuretics, and follow-up CT and renal Doppler ultrasonography revealed improvements in IVC compression and renal venous flow pattern, respectively. Renal venous congestion has been often reported to be associated with acute decompensated heart failure and, to our knowledge, this is the first report to describe trauma-induced renal venous congestion. Trauma patients are at risk for renal venous congestion due to massive blood transfusion after recovery from hemorrhagic shock; therefore, if they develop AKI that cannot be explained by other etiologies, physicians should consider the possibility of trauma-induced renal venous congestion and perform renal Doppler ultrasonography.
Topics: Aged; Female; Humans; Hyperemia; Kidney Diseases; Liver; Shock, Hemorrhagic; Ultrasonography; Wounds and Injuries
PubMed: 33038002
DOI: 10.1007/s13730-020-00540-3 -
The Journal of Trauma Oct 2008
Review
Inflammation and the host response to injury a large-scale collaborative project: patient-oriented research core standard operating procedure for clinical care X. Guidelines for venous thromboembolism prophylaxis in the trauma patient.
Topics: Anticoagulants; Clinical Protocols; Emergency Treatment; Female; Humans; Inflammation; Injury Severity Score; Male; Patient Participation; Practice Guidelines as Topic; Primary Prevention; Program Evaluation; Sensitivity and Specificity; Survival Analysis; Thromboembolism; Treatment Outcome; Vena Cava Filters; Wounds and Injuries
PubMed: 18849816
DOI: 10.1097/TA.0b013e3181826df7 -
Journal of Vascular Surgery Jun 2020Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought...
OBJECTIVE
Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.
METHODS
The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.
RESULTS
From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).
CONCLUSIONS
In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.
Topics: Abdominal Injuries; Accidents, Traffic; Adult; Aged; Aorta, Abdominal; Databases, Factual; Female; Hemopneumothorax; Humans; Incidence; Male; Middle Aged; Multiple Trauma; Pedestrians; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; United States; Vena Cava, Inferior; Wounds, Nonpenetrating; Young Adult
PubMed: 31699513
DOI: 10.1016/j.jvs.2019.07.095 -
Prehospital Emergency Care 2016The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether...
BACKGROUND
The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology.
METHODS
Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2-8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement.
RESULTS
A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use.
CONCLUSION
The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.
Topics: Adult; Cohort Studies; Emergency Medical Services; Extremities; Female; Hemorrhage; Humans; Male; Middle Aged; Registries; Retrospective Studies; Tourniquets; Trauma Centers; United States; Wounds and Injuries
PubMed: 27245978
DOI: 10.1080/10903127.2016.1182606 -
Journal of Vascular Surgery Nov 2013Vascular trauma from large-dog bites present with a combination of crush and lacerating injuries to the vessel, as well as significant adjacent soft tissue injury and a...
BACKGROUND
Vascular trauma from large-dog bites present with a combination of crush and lacerating injuries to the vessel, as well as significant adjacent soft tissue injury and a high potential for wound complications. This retrospective case series evaluates our 15 years of experience in managing this uncommonly seen injury into suggested treatment recommendations.
METHODS
From our database, 371 adult patients presented with dog bites between July 1997 and June 2012. Twenty (5.4%) of those patients had vascular injuries requiring surgical intervention. Patient demographics, anatomic location of injury, clinical presentation, imaging modality, method of repair, and complication rates were reviewed to assess efficacy in preserving limb function. Pediatric patients were managed at the regional children's hospital and, therefore, not included in this study.
RESULTS
Among the 20 surgically treated vascular injuries, there were 13 arterial-only injuries, two venous-only injuries, and five combination arterial and venous injuries. Seventeen patients (85%) had upper extremity injuries; three patients had lower extremity injuries (15%). The axillobrachial artery was the most commonly injured single vessel (n = 9/20; 45%), followed by the radial artery (n = 4/20; 20%). Surgical repair of vascular injuries consisted of resection and primary anastomosis (four), interposition bypass of artery with autogenous vein (13), and ligation (two), with (one) being a combination of bypass and ligation. All patients had debridement of devitalized tissue combined with pulse lavage irrigation and perioperative antibiotics. Associated injuries requiring repair included muscle and skin (n = 10/20; 50%), bone (n = 1/20; 5%), nerve (n = 1/20; 5%), and combinations of the three (n = 5/20; 25%). Postoperative antibiotic therapy was administered for 14.7 ± 8.2 days in all 20 patients. Four patients (20%) developed postoperative wound infections, although this did not compromise their vascular repair. Of the patients compliant with postoperative surveillance, all limbs (100%) were viable at discharge and at 1-year follow-up.
CONCLUSIONS
Dog bite vascular injuries are an uncommon occurrence, where extremity pulse abnormalities are the most common presentation. These injuries are also associated with significant adjacent soft tissue trauma, which warrants aggressive debridement and perioperative antibiotic therapy. Despite vigilant management, nearly one-fifth of our patients sustained wound infections. All infections were successfully managed with broad-spectrum antibiotics, and all limbs were preserved 1-year postoperatively.
Topics: Adolescent; Adult; Aged; Anastomosis, Surgical; Animals; Anti-Bacterial Agents; Arteries; Bites and Stings; Child; Debridement; Dogs; Female; Humans; Ligation; Male; Middle Aged; Multiple Trauma; Retrospective Studies; Soft Tissue Injuries; Time Factors; Treatment Outcome; Vascular Grafting; Vascular Surgical Procedures; Vascular System Injuries; Veins; Wound Infection; Young Adult
PubMed: 23891489
DOI: 10.1016/j.jvs.2013.05.101 -
European Journal of Applied Physiology Feb 2012A key process in the pathophysiological steps leading to decompression sickness (DCS) is the formation of inert gas bubbles. The adverse effects of decompression are... (Review)
Review
A key process in the pathophysiological steps leading to decompression sickness (DCS) is the formation of inert gas bubbles. The adverse effects of decompression are still not fully understood, but it seems reasonable to suggest that the formation of venous gas emboli (VGE) and their effects on the endothelium may be the central mechanism leading to central nervous system (CNS) damage. Hence, VGE might also have impact on the long-term health effects of diving. In the present review, we highlight the findings from our laboratory related to the hypothesis that VGE formation is the main mechanism behind serious decompression injuries. In recent studies, we have determined the impact of VGE on endothelial function in both laboratory animals and in humans. We observed that the damage to the endothelium due to VGE was dose dependent, and that the amount of VGE can be affected both by aerobic exercise and exogenous nitric oxide (NO) intervention prior to a dive. We observed that NO reduced VGE during decompression, and pharmacological blocking of NO production increased VGE formation following a dive. The importance of micro-nuclei for the formation of VGE and how it can be possible to manipulate the formation of VGE are discussed together with the effects of VGE on the organism. In the last part of the review we introduce our thoughts for the future, and how the enigma of DCS should be approached.
Topics: Animals; Brain; Decompression Sickness; Embolism, Air; Humans; Nitric Oxide; Veins
PubMed: 21594696
DOI: 10.1007/s00421-011-1998-9 -
Journal of Vascular Surgery. Venous and... Nov 2019Inferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a... (Comparative Study)
Comparative Study
OBJECTIVE
Inferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a complicated panel or spiral vein graft reconstruction to avoid the need for ligation. Collateral venous drainage may be sufficient to allow acceptable results from IVC ligation; however, previous studies have suffered from low numbers and have differing results. The aims of this study were to assess the outcomes of isolated IVC injuries overall and to compare IVC ligation with repair.
METHODS
Patients in the National Trauma Data Bank from 2007 to 2014 with an IVC injury were evaluated. Isolated IVC injury was defined as patients with nonvascular Abbreviated Injury Scale scores <4 and no other named vascular injury. The primary outcome was mortality; secondary outcomes were in-hospital amputation-free survival, major lower extremity amputation, lower extremity compartment syndrome, acute kidney injury (AKI), deep venous thrombosis (DVT), and pulmonary embolism (PE).
RESULTS
Overall, 1075 (0.018%) patients had IVC injuries and 443 met inclusion criteria. On univariate analysis, in comparing IVC ligation and primary repair, ligation was not associated with mortality (23% vs 16%; P = .102) but was associated with blunt mechanism (22% vs 11%; P = .009), higher fasciotomy rate (11% vs 0%; P < .001), trend toward lower in-hospital amputation-free survival (76% vs 84.4%, P = .056), and higher rates of AKI (9% vs 4%; P = .060) and PE (3% vs 1%, P = .087). Similarly, major lower extremity amputation, compartment syndrome, and DVT were not different between groups. IVC ligation was not independently associated with mortality (adjusted odds ratio [AOR], 1.54; P = .197), in-hospital amputation-free survival (AOR, 0.61; P = .141), major amputation (AOR, Inf; P = .99), lower extremity compartment syndrome (AOR, 0.82; P = .827), or PE (AOR, 6.72; P = .052), but it was independently associated with fasciotomy (AOR, 31.4; P = .002), AKI (AOR, 2.7; P = .048), and DVT (AOR, 2.3; P = .021).
CONCLUSIONS
IVC ligation was not independently associated with mortality or lower extremity amputation, but it was associated with AKI and need for fasciotomy.
Topics: Adult; Amputation, Surgical; Databases, Factual; Female; Humans; Injury Severity Score; Ligation; Limb Salvage; Male; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures; Vascular System Injuries; Vena Cava, Inferior; Young Adult
PubMed: 31515201
DOI: 10.1016/j.jvsv.2019.06.013 -
Journal of Vascular Surgery. Venous and... Jan 2020Injury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval... (Observational Study)
Observational Study
OBJECTIVE
Injury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval shunting and total vascular isolation, have been described, but are poorly tolerated in the severely injured patient. Endovascular repair is an attractive alternative strategy, but effective hemostasis of complex injuries requires an endograft that excludes the injury while permitting flow from the hepatic veins. Unfortunately, IVC and hepatic vein anatomy is highly variable and has not been clearly described in injured patients. Our purpose was to characterize critical human IVC morphology in trauma patients, and develop the design parameters of an off-the-shelf fenestrated endograft intended for caval deployment.
METHODS
One hundred consecutive adult trauma patients with an admission computed tomography scan including a portal venous phase of the abdomen were reviewed. Specific anatomic measurements including segmental IVC lengths and diameters were obtained. Multiple theoretical endografts were modeled to optimize caval coverage in the retrohepatic segment, assuming 10% to 40% oversizing for seal.
RESULTS
This sample population had a mean age of 50 years, height of 173 cm, and weight 84 kg. Seventy-one percent were male and 89% had a blunt mechanism of injury. The median caval length from the renal veins to right atrium was 111 mm (interquartile range [IQR], 102-120 mm), diameter was 22 mm (IQR, 19-26 mm), and hepatic venous orifice area was 336 mm (IQR, 267-432 mm). All patients had a landing zone of at least 12 mm in the suprahepatic and 10 mm in the suprarenal segments. Three models of graft length were developed to accommodate patients with segmental and overall dimensions in the smallest half, third quartile, and fourth quartile. These could provide 95% of patients with coverage of the retrohepatic segment without risk of hepatic or renal vein occlusion. Four graft diameters were developed for cross-sectional fit. Graft diameters of 20, 24, 30, and 38 mm could provide adequate coverage in, respectively, 11%, 35%, 49%, and 16% of patients. These combinations of graft length and diameter would accommodate 93% of patients.
CONCLUSIONS
We defined human IVC morphology essential for endovascular therapy and developed parameters for fenestrated IVC endografts to address retrohepatic caval injuries in trauma patients. Although additional study and testing are required, this proof-of-concept study supports the hypothesis that exclusion of the most devastating retrohepatic IVC injuries can be achieved with a reasonable number of off-the-shelf fenestrated endografts. These findings form the basis for additional research toward the development of novel devices for endovascular therapy of these often lethal injuries.
Topics: Abdominal Injuries; Adult; Aged; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Computed Tomography Angiography; Computer-Aided Design; Endovascular Procedures; Female; Humans; Male; Middle Aged; Phlebography; Proof of Concept Study; Prosthesis Design; Retrospective Studies; Self Expandable Metallic Stents; Vascular System Injuries; Vena Cava, Inferior
PubMed: 31843249
DOI: 10.1016/j.jvsv.2019.06.021