Nonpenetrating Injury Research Articles

Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP).

Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3-8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented. Thirty-six patients sustaining blunt head trauma and fitting our strict clinical and radiographic diagnosis of DAI were enrolled in our study. Inclusion criteria were severe head injury patients who did not regain consciousness after the initial impact, and whose CT scan demonstrated characteristic punctate hemorrhages of < 10 mm diameter at the greywhite junction, basal ganglia, corpus callosum, upper brainstem, or a combination of the above. Patients with significant mass lesions and documented anoxia were excluded. Their intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were compared to a control group of 36 consecutive patients with severe non-penetrating non-operative head injury, using the Analysis for Variance method. Eighteen (50.0%), six (16.7%), and twelve (33.3%) patients had types I, II, and III DAI, respectively. The admission Glasgow Coma Score (GCS) was higher for types I and II than for type III DAI. ICP was monitored from 23 to 165 hours, with a mean ICP for 36 patients of 11.70 mmHg (SEM = 0.75) and a range from 4.3 to 17.3 mmHg. Of all ICP recordings, of which 89.7%, (2421/2698) were < or = 20 mmHg. Average mean arterial pressure (MAP) was 96.08 mmHg (SEM = 1.69), and 94.6% (2038/2154) of all MAP readings were greater than 80 mmHg. Average cerebral perfusion pressure (CPP) was 85.16 mmHg (SEM = 1.68), and 90.1% (1941/2154) of all CPP readings were greater than 70 mmHg. This is compared to the control group mean ICP, MAP, and CPP of 16.84 mmHg (p = 0.000021), 92.80 mmHg (p = 0.18), and 76.49 mmHg (p = 0.0012). No treatment for sustained elevated ICP > 20 mmHg was needed for DAI patients except in two; one with extensive intraventricular and subarachnoid hemorrhage who developed communicating hydrocephalus, and another with ventriculitis requiring intrathecal and intravenous antibiotic treatments. Two complications, one from a catheter tract hematoma, and another with Staph epidermidis ventriculitis, were encountered. All patients, except type III DAI, generally demonstrated marked clinical improvement with time. The outcome, as measured by Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) was similarly better with types I and II than type III DAI. The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.

Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience.

Identification of blunt carotid injury prior to the development of ischemic symptoms requires aggressive screening of patients at risk. The treatment of these lesions has centered around long-term anticoagulation therapy. However, studies have revealed that many of these lesions persist despite medical treatment, as does the risk of distal embolization. The authors present a series of six patients who were successfully treated by means of endovascular stent placement for nonpenetrating carotid injuries. In the authors' experience this treatment requires only temporary anticoagulation therapy, results in immediate reconstruction of the injured vessel, obliterates pseudoaneurysms, and prevents distal embolization.

Causes and visual outcome of childhood eye injuries in Nigeria.

Two hundred and twenty-eight children of both sexes (152 males and 76 females) aged between 1 and 15 years treated for eye injuries at the University of Nigeria Teaching Hospital, Enugu, Nigeria were studied. The injuries were commonly sustained during domestic activities (29.8%), at play or sports (23.7%), in the schoolroom (16.7%) and during farm work (10.1%). Causative agents were mostly sticks, followed by stone missiles and other flying objects. There was a general delay in reporting to hospital in all types and degrees of severity of injuries, with only 28.5% reporting in the first 24 hours and as many as 10.5% after 1 month. How quickly the patient came to hospital was determined more by social and economic factors than by sex, age and type of injury. Visual outcome was best in patients with mild non-penetrating injuries and worst in those with severe penetrating injuries. Amongst the latter the outcome was worse when the posterior segment was involved than when the injury involved only the anterior segment. Our study showed that there has been a change in the causation of childhood eye injuries in the country compared with reports of 25 years ago. The visual outcome in our patients was worse than in reports from developed countries. This was due mainly to delay in seeking specialist treatment and lack of sophistication of the treatment, especially in severe cases.

Injury of the cervical spine associated with carotid and vertebral artery occlusion: case report and literature review

Injury of the vertebral artery and the cervical parts of the internal carotid arteries represents a rarely encountered combination of injuries, which increases the likelihood of infarction and carries the risk that one of the diagnoses could be missed. This rare injury is reported in l-2 per cent of blunt injuries to the neck6r9z1’. The close anatomic relationship between vertebral arteries and cervical vertebrae makes it likely that dislocating spinal injuries may cause stenosis or occlusion of one or both of these arteries12. Frequent findings are pseudoaneurysms’4, arterial embolP or occlusion of the vertebral artery13,22. Most common causes are penetrating injuries of the neck4,14 diving;, sports injuries such as football, wrestling or chiropractic manipulatiorP and closed injuries of the head and neck 5. This paper presents a case with non-penetrating injury of the neck in a young patient, causing injury to the cervical spine and to the vertebral and carotid arteries without neurological sequelae.

Haemorrhagic hydrops of the gallbladder

The gallbladder is afforded anatomical protection from external blunt injury, being cushioned by the surrounding omentum and intestines. Partially embedded in the liver substance and shielded by the bony cartilaginous rib cage, it is rarely injured. Although 70 per cent of injuries to the extrahepatic biliary tract involve the gallbladder, injury to this hollow viscus occurs in only 2-3 per cent of all blunt abdominal injury’,‘. The reason for this rarity is the ability of the surrounding structures to dissipate the kinetic energy that might otherwise damage the gallbladder. Indeed, the traumatized gallbladder is most often recognized incidentally during laparotomy performed for other intra-abdominal injuries. Isolated gallbladder trauma resulting from nonpenetrating injury is difficult to diagnose. The physical examination signs are not as evident as with other hollow organ injuries. This paper describes a case of isolated gallbladder injury in which acute cholecystitis developed as a result of blunt injury with spontaneous haemorrhage into the gallbladder lumen. Pathological examination did not reveal any wound of the gallbladder. The use of radiographic imaging techniques to facilitate early diagnosis is emphasized.

A Case of Ruptured Tricuspid Valve Due to Nonpenetrating Cardiac Injury Detected by Echocardiography

Cardiac contusion is an increasingly recognized entity in patients with nonpenetrating chest injury. Unfortunately, the diagnosis of cardiac trauma, particularly cardiac contusion, is imprecise and may be confounded by the presence of associated injuries, hypoxia, shock, and metabolic abnormalities. Symptomatic cardiac injury following blunt chest trauma is relatively rare, and valvular injury is even rarer. The valves most commonly affected are mitral and tricuspid. Although tricuspid regurgitations are usually asymptomatic and can resolve spontaneously, recent developments in echocardiography made possible the precise diagnosis of valvular injuries noninvasively. The authors report the case of triuspid regurgitation incidentally detected by echocardiography in a construction worker who had suffered multiple fractures.

Diagnosis of blunt carotid injury in patients with facial trauma

Objectives. The purpose of this study was to review the clinical and diagnostic findings associated with blunt carotid artery injury, provide information related to clinical outcome, and report the findings of a retrospective study comparing patients with nonpenetrating and penetrating carotid artery injuries and the attendant facial injuries. Study design. Twenty-one patients admitted to the hospital nonelectively with a subsequent diagnosis of penetrating (11 patients) or nonpenetrating (10 patients) carotid artery injuries were included in the study. Records were analyzed for demographic data, mechanism of injury and time to diagnosis, neurologic status, presence of facial injuries, and outcome. Results. Five patients had facial injuries associated with a blunt carotid artery abnormality; six patients had penetrating carotid wounds. Time from carotid injury by all mechanisms to diagnosis was 20 minutes to 12 hours (mean 4 hours). Seventeen patients survived their injury. Conclusion. Patients with completely asymptomatic head injuries and severe closed-head injuries must be given careful initial evaluation and subsequent secondary evaluation. The relatively high frequency of facial injuries associated with blunt carotid injury should alert the maxillofacial surgeon to consider the diagnosis.

Segmental renal infarction after blunt abdominal trauma: Clinical significance and appropriate management

Segmental infarction after blunt trauma is an uncommon type of injury occurring as a result of occlusion of a segmental renal artery. We retrospectively reviewed 32 cases of segmental renal infarction after nonpenetrating injury in order to assess the clinical significance and the most appropriate management. Thirty-five segmental infarcts were demonstrated by contrast medium-enhanced computed tomography (CT), 19 in the left and 16 in the right kidney. Twenty-five of the 35 infarcts (71%) occurred as an isolated renal injury. A distinct upper pole predilection for segmental infarct was observed. Angiography showed an occluded branch vessel without contrast medium extravasation in four cases. None of the 30 surviving patients experienced delayed renal hemorrhage or deterioration of renal function. Only 2 of 24 evaluable patients developed mild diastolic hypertension during follow-up. Our data indicate that segmental renal infarction in the blunt trauma patient, as demonstrated by contrast medium-enhanced CT, should be managed nonoperatively and requires no further evaluation with angiography.

Recognition and management of nonpenetrating cardiac trauma in children

OBJECTIVE. To characterize the evaluation and clinical course of children with nonpenetrating injury to the heart. METHODS. We reviewed the medical records for children admitted to St. Louis Children's Hospital between the years 1987 to 1992 with traumatic cardiac injury. Patients with penetrating trauma were excluded; eight children, ages 4 to 13 years, were the study subjects. Chest x-ray studies, electrocardiograms, and serum creatine kinase values were obtained on admission. Two-dimensional echocardiography was performed when indicated by unexplained hemodynamic instability or abnormal radiographic findings. RESULTS. All children with nonpenetrating cardiac trauma were involved in a motor vehicle accident. The principal cardiac diagnoses were ventricular septal defect (1), mitral regurgitation (1), pericardial effusion (2), contusion (3), and arrhythmia (1). Multisystem injury was present in each case, but cardiac injury was not suspected at the time of admission in seven of the eight patients. The hemodynamic status of four children was compromised 12 to 48 hours after admission; echocardiography was diagnostic in each instance, but the electrocardiogram and creatine kinase values were nonspecific. Two patients eventually required cardiac surgery. CONCLUSIONS. Recognition of blunt cardiac trauma in children may be confounded by associated multisystem injury and the delayed onset of clinical manifestations. Echocardiography is a sensitive diagnostic tool for hemodynamically significant disease, and should be performed promptly when patients have unexplained hypotension or diminished peripheral perfusion. (J P EDIATR 1996;128:536-41)

Natural history of post-traumatic seizures following nonpenetrating traumatic brain injury: Kenneth R. Kemp Jr, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD

Natural history of post-traumatic seizures following nonpenetrating traumatic brain injury: Kenneth R. Kemp Jr, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD

Impact of traumatic subarachnoid hemorrhage on outcome in nonpenetrating head injury

The presence of traumatic subarachnoid hemorrhage (tSAH) on admission computerized tomography (CT) scans obtained from patients suffering from severe, nonpenetrating head injury has been shown to be associated with a worse outcome than the injury alone would warrant. However, no previous study has provided a simple means of relating the amount of tSAH, its location, or other abnormal findings on initial head CT scans to outcome in patients with non-penetrating head injury. In this study, admission head CT scans from 252 patients with tSAH, treated at a single institution, were reviewed to ascertain thickness of the tSAH; its location; evidence of mass lesion(s); shift of midline structures (< or = 5 mm vs. > 5 mm); basal cistern effacement; and cortical sulcal effacement. The CT scans were then organized into Grades 1 to 4 with 1 indicating thin tSAH (< or = 5 mm); 2, thick tSAH (> 5 mm); 3, thin tSAH with mass lesion(s); and 4, thick tSAH with mass lesion(s). A stepwise regression analysis of CT features ranked them in descending order of contribution to Glasgow Outcome Scale (GOS) scores at the time of discharge from acute hospitalization as follows: basal cistern effacement, thickness of tSAH, cortical sulcal effacement, presence of mass lesion(s), and location of tSAH. A shift of midline structures was not found to be a significant variable. Further analysis comparing CT grades and admission postresuscitation Glasgow Coma Scale (GCS) scores was highly significant. Patients with lower CT grades had better admission GCS values and discharge GOS scores than those with higher CT grades. From their experience, the authors conclude that their CT grading scale is simple and reliable and relates significantly to outcome at the time of discharge from acute hospitalization.

PS-39-7 Peripheral and spinal SEPs in the extraoperative evaluation of the non-penetrating brachial plexus injuries

PS-39-7 Peripheral and spinal SEPs in the extraoperative evaluation of the non-penetrating brachial plexus injuries

Magnetic resonance imaging of acute tendon injury in the finger

Accurate assessment of flexor tendon function in a digit with an acute, non-penetrating injury is difficult. MR imaging can negate the need for surgical exploration and the associated morbidity.

18‐FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY IN CHILDREN AND ADOLESCENTS WITH TRAUMATIC BRAIN INJURY

Twenty-two previously normal children and adolescents who suffered a severe, non-penetrating traumatic brain injury had PET during rehabilitation at a median of 1.5 months after the injury. Outcome was assessed at a median of 25 months after brain injury. 16 subjects had CT or MRI within 24 days of PET and 11 subjects had a second PET at the point of outcome (median 28 months after first PET). The PET score (obtained by adding the score of 15 brain regions: normal metabolism = 1; reduced = 0) was significantly associated with the clinical outcome measure. PET earlier than 12 weeks after head trauma correlated with outcome, but later PET did not. PET scores improved significantly between rehabilitation and outcome for the 11 subjects who had two PETs, but improvement was not associated with improvement in clinical condition. PET score did not add to the amount of variance explained in the last regression model for prediction of outcome when the results of contemporaneous CT/MRI and clinical condition were taken into account. The data suggest that routine PET during rehabilitation is no more useful than contemporaneous CT or MRI for prediction of outcome.

Generalized autosensitization to a localized eczematoid dermatitis induced by ionizing radiation

Autosensitization was originally defined by Whitfield as form of autointoxication derived from changes in patient's own tissues. He reported three patients in whom a generalized skin eruption developed after a localized nonpenetrating cutaneous injury or a localized inflammatory dermatitis.' Subsequently has been reported in patients with dermatophyte infection, scabies, localized burn, localized bacterial infection.I stasis dermatitis.' and many other types of dermatitis. Later a more contemporary definition for was proposed by Rook, who stated that autosensitization is sensitization of body by circulating antibody, or a delayed cellular-type antibody, or both, to constituents of its own tissues. The most recognized form of dermatitis is autoeczematization, defined as the process by which a widespread dermatitis may complicate several types of localized eczema.? Radiotherapy causes several types of acute skin reaction/' The most common is primary reaction at treatment site that usually consists of dry or moist erythema, desquamation, or both.' At high dosages of radiation, blisters, erosions, or ulcerations may occur. Another type of skin reaction is a localized eczematoid dermatitis that is either confined to treatment sites or contiguous areas. A rare reaction is a generalized erythema multiforme-like eruption in patients who received deep radiothera-

Animate models of human head injury.

A review of animal models of nonpenetrating head injury caused by mechanical energy is presented that focuses on the ability of various categories of models and their relationships to the types of head injury seen in humans. Basic hypotheses of animal modeling of human disease and outcome measures are addressed. Current models are reviewed and compared for their differences and similarities regarding behavioral, pathologic, physiologic, and biochemical fidelity to human head injury.

後頭蓋か陥没骨折に合併したＷａｌｌｅｎｂｅｒｇ症候群の１例

A rare case of Wallenberg's syndrome associated with a depressed facture in the posterior cranial fossa is reported. A 37-year-old male was admitted to our hospital because of a consciousness disturbance, immediately after falling from a height. On admission he was found to be in a state of drowsiness. Initial CT scans showed a depressed fracture with disappearance of the fourth ventricle and the cisterns, and his condition gradually deteriorated. Suboccipital decompressive craniectomy was then performed, and his condition improved. Neurological examination on day 5, however, disclosed signs of a typical right Wallenberg's syndrome. The right posterior inferior cerebellar artery (PICA) could not be identified on vertebral angiography. Magnetic resonance imaging (MRI) showed a small infarct in the right dorsolateral medulla. Occlusion of the vertebral artery territory due to a nonpenetrating injury is discussed, and comments are made on the mechanisms involved in our patient, with a selective review of the literature.

Delayed papillary muscle rupture following non-penetrating chest injury

Delayed papillary muscle rupture following non-penetrating chest injury

Diagnosis, Management, and Complications of Nonpenetrating Cardiac Trauma: A Perspective for Practicing Clinicians

We provide a state-of-the-art review for practicing clincians concerning diagnosis and treatment of patients with non-penetrating cardiac trauma. Internists, cardiologists, and intensivists are becoming increasingly involved in the diagnosis and management of patients with nonpenetrating cardiac injuries. Electrocardiography and cardiac isoenzyme determinations are the least expensive and most common laboratory tests used to diagnose this condition. Despite widespread use, however, these tests have significant limitations in diagnostic sensitivity and specificy. Two-dimensional echocardiography is advocated by some to improve diagnostic accuracy and to identify patients at increased risk of cardiovascular complications. Patients identified as low risk may be suitable for limited monitoring and early hospital discharge. Transesophageal echocardiography is a useful diagnostic tool that offers many advantages over standard transthoracic imaging. Nuclear medicine techniques, including radionuclide-labeled antimyosin scanning, also represent exciting new developments in this area. Invasive techniques such as cardiac catheterization and pumonary artery catheterization should be reserved for patients with hemodynamic instability and overt mechanical complications. Appropriate selection of diagnostic tests can assist clinicians in rapid traging of patients with nonpenetrating cardiac trauma. Identification of patients at low risk for cardiovascular complications may lead to more appropriate use of hospital resources.

A Phase II Study of Moderate Hypothermia in Severe Brain Injury

Forty-six patients with severe nonpenetrating brain injury [Glasgow Coma Scale (GCS) 4-7] were randomized to standard management at 37 degrees C (n = 22) and to standard management with systemic hypothermia to 32 to 33 degrees C (n = 24). The two groups were balanced in terms of age (Wilcoxon's rank sum test, p > 0.95), randomizing GCS (chi-square test, p = 0.54), and primary diagnosis. Cooling was begun within 6 h of injury by use of cooling blankets. Metocurine and morphine were given hourly during induction and maintenance of hypothermia. Rewarming was at a rate of 1 degree C per 4 h beginning 48 h after intravascular temperature had reached 33 degrees C. Muscle relaxants and sedation were continued until core temperature reached 35 degrees C. There were no cardiac or coagulopathy-related complications. Seizure incidence was lower in the hypothermia group (Fisher's exact text, p = 0.019). Sepsis was seen more commonly in the hypothermia group, but difference was not statistically significant (chi-square test). Mean Glasgow Outcome Scale (GOS) score at 3 months after injury showed an absolute increase of 16% (i.e., 36.4-52.2%) in the number of patients in the Good Recovery/Moderate Disability (GR/MD) category as compared with Severe Disability/Vegetative/Dead (SD/V/D) (chi-square test, p > 0.287). Based on evidence of improved neurologic outcome with minimal toxicity, we believe that phase III testing of moderate systemic hypothermia in patients with severe head injury is warranted.