Thoracoabdominal Trauma Research Articles

Hérnia Diafragmática à Direita: Um Relato de Caso

Resumo: Relato de caso de um paciente com hérnia diafragmática direita crônica. Paciente em emergência de hospital referência de trauma com obstrução intestinal grave. Hérnia diafragmática pós-traumática é uma injúria pouco encontrada na prática médica, principalmente quando acomete o hemidiafragma direito. As rupturas do lado direito estão associadas a alta morbi-mortalidade e, portanto, o subdiagnóstico de lesões à direita pode ser devido a uma maior mortalidade pré-hospitalar ou a um atraso no diagnóstico intra-hospitalar, muitas vezes em consequência do grau variável de acometimento traumático. A ruptura diafragmática contusa, por ser uma condição pouco frequente, deve ter alto índice de suspeição nos pacientes vítima de trauma tóraco-abdominal, independente do mecanismo de trauma. A associação com lesões múltiplas e graves é frequente, apresentando considerável taxa de morbi-mortalidade, devido aos riscos de complicações imediatas e tardias envolvidas no atraso diagnóstico.

Rendimiento diagnóstico de la tomografía computarizada multidetector para la identificación de heridas diafragmáticas en pacientes hemodinámicamente estables. Resultados preliminares

Introducción. Las heridas diafragmáticas son un hallazgo común en pacientes con trauma toracoabdominal penetrante. Su diagnóstico requiere exploración mediante cirugía abierta o laparoscópica. Sin embargo, la tomografía computarizada multidetector (TCMD) surge como una herramienta no invasiva útil para este propósito. Objetivo. Determinar el rendimiento diagnóstico de la TCMD en la identificación de heridas diafragmáticas en pacientes con trauma toracoabdominal penetrante hemodinámicamente estables. Materiales y métodos. Estudio prospectivo realizado en 119 pacientes atendidos en el Hospital Universitario del Valle, Cali, Colombia, entre marzo de 2012 y junio de 2015. Para evaluar el rendimiento diagnóstico de la TCMD, los resultados obtenidos mediante esta prueba fueron comparados con los reportados por el test de referencia (cirugía abierta). Se realizaron 2 lecturas de los estudios de imagen por 2 radiólogos. La concordancia intra e interobservador respecto a la lectura de las TCMD se analizó mediante el coeficiente Kappa de Fleiss. Resultados. La TCDM tuvo una sensibilidad y especificidad de 94.4% y 46.8%, respectivamente. Sus valores predictivos positivo (VPP) y negativo (VPN) fueron 44.7% y 94.8%, respectivamente. La razón de verosimilitud positiva (LR+) fue 1.7765, y la razón de verisimilitud negativa (LR-), 0.1186. Respecto a la concordancia interobservador, el coeficiente Kappa de Fleiss entre la primera lectura de ambos radiólogos fue de 0.4425. Conclusiones. La especificidad de la TCMD para el diagnóstico de heridas diafragmáticas encontrada en el presente estudio difiere considerablemente de lo reportado en la literatura. Teniendo en cuenta la sensibilidad, el VPN y la LR- obtenidos en el presente estudio, la TCMD podría constituir una herramienta importante en el manejo de estos pacientes, ya que en aquellos en los que no se detecte herida diafragmática mediante este tipo de tomografía podría considerarse un manejo conservador.

Obesity Protects Against Operation in Pediatric Penetrating Trauma to the Torso

BackgroundStudies in the adult population are conflicting regarding whether obesity is protective in penetrating trauma. In the pediatric population, data on obesity and penetrating trauma are limited. We sought to determine if there is a different rate of operation or of survival in pediatric and adolescent patients with obesity. MethodsWe queried the National Trauma Data Bank research data set from 2013 to 2016 for all patients aged 2-18 who sustained traumatic penetrating injuries to the thorax and abdomen. The cohort was divided into body mass index percentiles for gender and age using Center for Disease Control definitions. Outcomes included overall survival, whether or not an operative procedure was performed, and hospital and intensive care unit (ICU) length of stay. ResultsWe analyzed 9611 patients with penetrating trauma, of which 4285 had an operative intervention. When adjusted for other variables (age, gender, race, ICU length of stay, hospital length of stay, and Injury Severity Score), children of every body mass index percentile had similar survival. Healthy weight patients were more likely to get an operation than patients in the obese category. Length of hospital stay was similar between groups, but the ICU length of stay was longer in the overweight and obese groups compared with healthy weight and underweight groups. ConclusionsChildren and adolescents with obesity are less likely to undergo operation after penetrating thoracoabdominal trauma. Further study is needed to determine the reason for this difference.

Acute Diaphragmatic Injuries Associated with Traumatic Rib Fractures: Experiences of a Major Trauma Centre and the Importance of Intra-Pleural Assessment.

BackgroundDiaphragmatic injuries following blunt or penetrating thoraco-abdominal trauma are rare, but can be life-threatening. Rib fractures are the most common associated injury in patients with a traumatic diaphragmatic injury (TDI). We hypothesized that the pattern of rib fracture injuries could dictate the likelihood of acute TDIs.MethodsA retrospective study was carried out between April 2014 and October 2018 to analyze patients with TDIs and rib fractures at a major trauma center in London, United Kingdom.ResultsOver the study period, 1,560 patients had rib fractures, of whom 14 had associated diaphragmatic injuries. Left-sided diaphragmatic injuries were found in 8 patients (57%) . A significant proportion of the rib fractures were located posterolaterally (44.9%). The highest frequency of fractures was found in ribs 5–10, which accounted for 74% of all the fractures. Ten patients underwent surgery, of whom 7 were diagnosed with a diaphragmatic injury intraoperatively after video-assisted thoracoscopic surgery assessment of the pleural cavity. Two patients died due to severe injuries of other organs and the remaining 2 patients were managed conservatively.ConclusionOur series of patients demonstrates a relationship between significant rib fractures and diaphragmatic injuries in trauma patients, and the diagnostic difficulties in identifying the condition. We found that the location of the rib fractures and the pattern of injury in patients with TDIs were much lower and posterolateral in the chest wall without a preference for laterality. We suggest using a thoracoscope in patients undergoing chest wall surgery post-trauma to aid in diagnosing this condition.

Emergency Room Thoracotomy (ERT): A retrospective audit of results.

Background: An Emergency Room Thoracotomy (ERT) is a resource-intensive, high-risk procedure in which rapid decision-making is essential. In a resource-constrained system, identification of the group of patients that could achieve the best outcome will avoid futile use. Incorporating physiological and metabolic parameters at the time of arrival to the emergency department into the management algorithm may assist with better patient selection and could improve outcomes.
 Material and Methods: A retrospective review of the results of subjects who underwent Emergency Room Thoracotomy at a Level 1 Academic Trauma Center over a 13-year period (01 January 2005 to 31 December 2017) was conducted. Mechanism of injury, physiological and metabolic parameters, anatomical injuries, Injury Severity Score (ISS), calculated Revised Trauma score (cRTS), volume and type of fluids administered, and mortality were analyzed comparing survivors and non-survivors.
 Results: One hundred and ten (n=110) patients underwent ERT during the study period. Variables such as the mechanism of injury, physiological and metabolic parameters, type, and volume of fluids administered did not show any statistically significant influence in the final outcome. Penetrating cardiac and chest trauma had better survival (40.6 % and 20 % respectively) compared to those with thoraco-abdominal, abdominal, pelvic, and femoral vessel trauma. Overall survival was 21,8%.
 Conclusions: In a resource-constrained environment an Emergency Room Thoracotomy should be performed in patients with a thoracic injury, especially cardiac, to achieve the best possible outcome.

Determinants of mortality and intensive care requirement in pediatric thoracoabdominal injuries.

Thoracoabdominal injuries (TAI) are an important cause of trauma-related morbidity in children. Early and correct intervention is essential to reduce mortality. We aimed to determine factors associated with mortality and the need for intensive care in TAI. The children admitted to the pediatric emergency department of a tertiary care hospital with TAI in a 6-year-period were enrolled. Demographic data; mechanism of injuries; clinical, laboratory and imaging findings; length of hospital and intensive care unit (ICU) stay; invasive procedures and medical treatments; surgical interventions; and survival outcomes were recorded. The median age of the 136 children was 9 (IQR: 5-14) years and 72.8% were male. The vast majority of injuries were caused by blunt trauma (92.7%). Pulmonary contusion, pneumothorax, splenic, and liver injuries were the most common diagnoses. Motor vehicle accidents were seen in more than half of the cases (52.2%). The median length of hospital stay was 5 (IQR: 2-8) days; 21 patients were hospitalized in the ICU (15.4%). The need for intensive care was higher in patients with lower Glasgow Coma Scale (GCS) scores and lower Pediatric Trauma Scores (PTSs), in the presence of multiple injuries, pulmonary contusion, and pneumothorax (p<0.001). Mortality was seen in nine patients, eight of whom had multiple injuries. The mortality rate was higher in patients with pulmonary contusion and pneumothorax (p=0.002 and p=0.003, respectively). The PTS and GCS were found to be lower in patients who died in hospital (p<0.001). Prolongation of coagulation parameters and hyperglycemia was more common in the non-survivor group (p=0.005 and p=0.004, respectively). Although thoracoabdominal trauma is not common in childhood, it is an important part of trauma-associated mortality. Multiple injuries, pulmonary contusion, pneumothorax, lower GCS, and PTSs can be a sign of serious injuries to which physicians must be alert.

A national study of emergency thoracotomy for trauma

Introduction:The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT).Methods:The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets.Results:The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215.Conclusion:Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.

Post-traumatic thoracic splenosis

Splenosis is a rare disease and defined as spleen tissue autotransplantation following spleen rupture and subsequent splenectomy in most cases. The authors report ectopic splenic tissue in pleural cavity diagnosed in 31 years after blunt thoracoabdominal trauma.

Prognostic value of lactate to hematocrit ratio score in patients with severe thoracoabdominal trauma.

Significant portion of trauma-related deaths occur in the 1st h; therefore, rapid diagnosis and adequate resuscita-tion in trauma patients are essential preventing mortality. In this study, we aimed to evaluate the role of lactate-to-hematocrite ratio (LHR) score for predicting mortality in patients with severe thoracoabdominal trauma. In this retrospective, cross-sectional study, we evaluated patients who applied to the emergency room between January 1, 2016, and December 31, 2019, due to multiple trauma. We measured the blood gas analysis values and LHR score of patients with severe thoracoabdominal trauma included in the study and investigated the effectiveness of the LHR score in predicting mortality. 106 patients with severe thoracoabdominal trauma were included in the study. The 30-day mortality rate of the patients was 42.5% (n=45). Considering the 30-day mortality rates, the initial hematocrit, lactate, base deficit, and LHR score were statistically different between patients who died and survived. When the cutoff value for the LHR score was taken as 0.187 on the ROC curve to distinguish mortality, the sensitivity was found to be 77.8%, specificity to be 90.2%. LHR score is an effective parameter with high sensitivity and specificity in predicting mortality in patients with severe thoracoabdominal trauma.

Diagnosis of Traumatic Pneumothorax: A Comparison between Lung Ultrasound and Supine Chest Radiographs.

Background/ObjectiveTraumatic pneumothorax is an ominous condition necessitating urgent appropriate action. It is typically detected on chest X-rays; however, these may not be able to detect the presence of a subtle pneumothorax, especially in supine position. Lung ultrasound is emerging as a promising modality for detecting pneumothorax in trauma patients. The aim of our study was to compare ultrasound with supine chest radiography for the detection of pneumothorax in trauma patients.Materials and MethodsThis was a prospective, single-blinded study carried out on 212 adult thoracoabdominal trauma patients who underwent ultrasound FAST and supine (AP) chest radiography. During the FAST sonography, ultrasound thorax was done to rule out pneumothorax. Only those cases were considered (118) in which the presence or absence of pneumothorax could be confirmed on CT done subsequently or where pneumothorax was confirmed by air escape on chest tube placement, wherever indicated, and the results were compared with sonographic and chest X-ray findings.Observation/ResultsThere were 48 true positives on CT/chest tube insertion. Among these, ultrasound was able to correctly detect pneumothorax in 43 patients, while supine chest X-rays correctly identified 33 cases. Sensitivity of ultrasound was 89.6 vs. 68.8% of supine chest radiography. Lung ultrasound also had a higher negative predictive value as compared to supine chest X-rays.ConclusionsLung ultrasound is more sensitive in detecting traumatic pneumothorax than supine chest X-rays, in addition to having numerous other inherent advantages over chest radiography. It should be incorporated in the emergency assessment of thoracic trauma patients to rule out pneumothorax.Clinical significanceLung sonography is more sensitive in detecting traumatic pneumothorax than supine chest X-rays. No added equipment is required, and the procedure can be carried out at the time of doing ultrasound FAST, thus saving precious time in trauma patients.How to cite this articleBhoil R, Kumar R, Kaur J, Attri PK, Thakur R. Diagnosis of Traumatic Pneumothorax: A Comparison between Lung Ultrasound and Supine Chest Radiographs. Indian J Crit Care Med 2021;25(2):176–180.

Instant intra-operative neutropenia despite the emergence of banded (CD16dim/CD62Lbright) neutrophils in peripheral blood - An observational study during extensive trauma-surgery in pigs

IntroductionDeregulation of polymorphonuclear neutrophils (PMNs) is an essential step in the development of inflammatory complications upon trauma. Different neutrophil subtypes have been identified recently, however, the role of neutrophil subtypes in immunoregulation upon trauma is unclear. We hypothesize that extensive trauma surgery causes instant progressive heterogeneity of the blood neutrophil pool, and increased appearance of young (CD16dim/CD62Lbright) neutrophils in peripheral blood. Material and methodsA standardized extensive thoraco-abdominal porcine trauma surgery model was utilized, and 12 animals were included. Blood was collected at defined timepoints and neutrophil numbers and subtypes were studied by flowcytometry. Neutrophil subtypes were identified by differences in cell surface expression levels of CD16 (FcγRIII) and CD62L (L-selectin). Porcine neutrophil subtypes were further characterized after flow sorting. ResultsEleven animals survived the 3-hour surgical protocol. Neutrophil numbers dropped significantly from a mean of 8,6 ± 3,5 × 106 to 2,4 ± 1,8 × 106 cells/ml during 180 min, (p<0.001). Simultaneously, the blood PMN population became increasingly heterogeneous due to the appearance of new neutrophil subtypes. Cell sorting experiments and cytological analysis revealed that these porcine subtypes had specific morphological characteristics, mimicking their human counterparts. At baseline, 88% ± 1 percent of circulatory PMNs comprised of mature (CD16bright/CD62Lbright) PMNs, while at 3 h the blood PMN pool consisted of 59% ± 2 percent of mature subtypes (p<0.001). Despite a marked drop in neutrophil levels during surgery, absolute and relative numbers of banded (CD16dim/CD62Lbright) neutrophils continued to rise throughout surgery. ConclusionStandardized extensive trauma surgery was associated with instant progressive neutropenia and increased heterogeneity of the blood neutrophil pool. Furthermore, three different neutrophil subsets in peripheral porcine blood were identified over the course of surgery. Further studies should clarify their precise role in the development of early organ failure upon extensive trauma surgery. This for the first time exemplifies experimentally the time constraints and impact of damage control surgery after severe trauma.

Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma.

The initial evaluation of patients with thoracic trauma remains a diagnostic challenge for surgery and emergency physicians. Chest sonography plays a key role in the approach for this group of patients, through extended and focused evaluation with trauma sonography (E-FAST). To establish the diagnostic performance of the extension of the thoracic spine sign using chest sonography in trauma to diagnose hemothorax and compare it with the gold standard test chest computed tomography (CT). This prospective observational study was conducted over 1year. Patients who attended the emergency room with closed or penetrating thoracic or thoraco-abdominal trauma, an indication for a chest CT as part of a diagnostic evaluation according to institutional protocols, and who previously underwent a chest sonogram to determine the extent of the thoracic spine sign to diagnose hemothorax. Sonographic results were compared to a radiologist's interpretation of the chest CT. The radiologists were blinded to the initial sonogram interpretation. Seventy-six patients were enrolled with an average age of 32years. They mainly had closed trauma, which accounted for 77.6% of samples, and 222 chest images were taken. The sensitivity and specificity for this study were 78.7% and 92.6%, respectively, with a positive predictive value and negative predictive value of 65% and 97.8%, respectively. Extension of the thoracic spine sign allows rapid identification of the presence, and more precisely, the absence of pleural effusion. This, therefore, allows an appropriate diagnosis and approach in the emergency room in patients with chest trauma.

Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma

BackgroundTraumatic diaphragmatic injuries (TDIs) are relatively uncommon and require surgical repair to prevent or address herniation. Three quarters of TDIs are due to blunt thoraco-abdominal trauma. In blunt TDIs, variable clinical presentations and frequent concurrent life-threatening injuries may hinder early recognition and treatment, leading to diagnostic delays, which may result in technically more challenging repairs. Right-sided blunt TDIs are much less common than left-sided ones, are difficult to visualize on imaging studies, are more frequently associated with other potentially lethal injuries, and tend to present more subtly, so that diagnostic delays are more likely.Case presentationWe report the diagnosis and elective repair of a large right-sided traumatic diaphragmatic hernia resulting from a distant blunt abdominal injury, describing the techniques used to address the challenges presented by the chronic intrathoracic displacement of the entire liver with the gallbladder, as well as the right side of the colon and part of the duodenum.ConclusionsEarly diagnosis of right-sided TDIs can be especially elusive. The management of delayed diaphragmatic hernias can be challenging, but with meticulous planning and a flexible surgical approach, a repair can be achieved resulting in good recovery and low risk of recurrence.

Imaging evaluation of diaphragmatic injuries: Improving interpretation accuracy

Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic delayed complications. A high degree of suspicion in every case of severe blunt thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This review will present the evidence and controversies on this topic providing a practical tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues will be presented.

The role of diagnostic laparoscopy for trauma at a high-volume level one center.

BackgroundThe role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries.ObjectiveWhile the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center.MethodsAll trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated.ResultsA total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4–18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05).ConclusionIn this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

The Abdominal Traumatized Patient between Emergency Service and Discharge

Abstract Due to the changes in major trauma epidemiology, the management of thoracoabdominal trauma evolved in time. The thoracoabdominal major lesions were treated in the past by emergency laparotomy or tocachotomy. The morbidity associated with nontherapeutic laparotomies or thoracotomies lead to an increase of using conservative ways of treatment. We accomplished a retrospective study in which we included 234 patients, all of them diagnosed with thoracoabdominal trauma who were hospitalized in the General Surgery Ward. The objective of this study is to determine whether there is a correlation between the value of hematocrit and hemoglobin at patient admission and the values at discharge, in patients who required blood transfusion during hospitalization.

Awake Emergency Department Thoracoscopic Investigation of Penetrating Diaphragmatic Injuries: A Novel Minimally Invasive Technique of Diagnosis.

Background: The diagnosis of occult penetrating diaphragmatic trauma remains challenging, with conventional imaging offering inadequate accuracy for diagnosis. Minimally invasive surgical options for evaluating the diaphragm conventionally require general anesthesia. We propose a technique for evaluating the diaphragm via awake thoracoscopy in the emergency department. Methods: A prospective interventional study was conducted to investigate the safety and accuracy of emergency department awake thoracoscopy for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma. All adult patients who presented to the trauma unit with penetrating thoracoabdominal trauma who were hemodynamically stable were enrolled. The patients underwent emergency department awake thoracoscopy with a rigid endoscope through a previously inserted intercostal drain. Only local anesthesia and conscious sedation were provided. Results: Forty patients were enrolled. All 40 (100%) were men, and the median age was 34 years. Thirty-four had stab wounds (85%), 5 had gunshot wounds (12.5%), and 1 had a suspected iatrogenic diaphragm injury during intercostal drain insertion (2.5%). In 32 (80%), the diaphragm was well visualized, of whom 7 (17.5%) had diaphragm injuries. In the remaining 8 patients in whom the diaphragm was not well visualized, only 1 (2.5%) had a diaphragmatic injury. The diaphragmatic injuries that were identified were confirmed and repaired during a subsequent explorative laparoscopy. There were no procedure-related complications in any of the patients during short-term follow-up. Conclusions: Awake thoracoscopy is safe, feasible, and accurate for the diagnosis of occult diaphragm injuries and may offer a modality for assessment that does not require general anesthesia.

Tension Viscerothorax in a Patient with Missed Traumatic Diaphragmatic Hernia. A Case Report.

Background: Diaphragmatic hernias occurring post trauma are a challenge to diagnose early especially when they follow blunt trauma. Many of those diagnosed early occur in penetrating thoraco-abdominal trauma which necessitates emergency exploration where the diagnosis is picked. Rarity of traumatic diaphragmatic hernia coupled with poor sensitivity of easily available imaging modalities makes it a big challenge to pick up this potentially fatal pathology.&#x0D; Case presentation: We present a rare case of tension viscerothorax in a young man who had presented to the emergency department at a provincial hospital of Rwanda three days before the second consultation where the chest x-ray was interpreted as normal and later as a pneumothorax before the diagnosis and treatment of tension viscerothorax could be made.&#x0D; Conclusion: Viscerothorax is an elusive diagnosis which when missed can complicate to strangulation of hernia contents or tension viscerothorax which carry a high mortality.

A case of bilateral endogenous endophthalmitis misdiagnosed as Purtscher\u2019s retinopathy

BackgroundPurtscher’s retinopathy characterized by the appearance of cotton-wool spots and intraretinal hemorrhage at the posterior pole that commonly occurs after severe head and chest trauma. We report a patient who presented with multiple white retinal patches and retinal hemorrhage forty-two days after a severe thoracoabdominal trauma, which was misdiagnosed as Purtscher’s retinopathy.Case presentationA middle-aged woman presented to the eye clinic complaining of decreased vision and distortion in the right eye forty-two days after thoracoabdominal trauma. Upon first glance at her fundal appearances with multiple white retinal patches and retinal hemorrhage, we considered it to be bilateral Purtscher’s retinopathy. No specific treatment was given to her. Ten days later, the four white retinal patches in the right eye joined together with star-shaped hard exudates and radial folds in the macula. This was not consistent with the characteristics of Purtscher’s retinopathy. In retrospect, we found that the onset time, shape, and location of the white retinal patches were not cotton-wool spots. A detailed history revealed that she had Staphylococcus aureus septicaemia due to abdominal incision infection, and she underwent intravenous antibiotic therapy. Fundus fluorescein angiography (FFA) revealed hyperpermeable vasculature and extensive fluorescence leakage in the middle and late stages. Optical coherence tomography (OCT) revealed highly reflective exudates in the neuroepithelium and macular edema in the right eye. Taking her history and the FFA and OCT results into consideration, she was diagnosed with bilateral endogenous endophthalmitis.ConclusionIn the present case, multiple white patches and intraretinal hemorrhage at the posterior pole forty-two days after the trauma were not Purtscher’s retinopathy. It was bilateral endogenous endophthalmitis. The subretinal abcesses that developed secondary to Staphylococcus aureus infection involved the macula causing decreased vision and distortion in the right eye. We concluded that in the case of multiple white retinal patches at the posterior pole in patients after trauma, especially in patients with infectious disease, Purtscher’s retinopathy is not the only possible diagnosis. Correct diagnosis depends on reevaluation of the lesions by FFA and OCT, laboratory investigation and detailed history.

HEART WITH SOME GUTS: TRAUMA INDUCED INTRA-PERICARDIAL DIAPHRAGMATIC HERNIA

Intrapericardial diaphragmatic hernia (IDH) can occur from traumatic, congenital or iatrogenic diaphragmatic defect of central tendon. In patients with thoracoabdominal trauma, it is relatively rare and has been reported in less than 1% of cases. 63-year-old female with Idiopathic thrombocytopenic