Travma 2012-4

Cilt - Volume 18

Say› - Number 4

www.tjtes.org

Temmuz - July 2012

Cilt - Volume 18

Sayı - Number 4

Temmuz - July 2012

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan Geçmiş Dönem Editörleri (Former Editors) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD) Fatih Ağalar Yılmaz Akgün Levhi Akın Alper Akınoğlu Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Nevzat Alkan Edit Altınlı Acar Aren Gamze Aren Cumhur Arıcı Oktar Asoğlu Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Önder Aydıngöz Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Mehmet Can Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale M. Ercan Çetinus Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Kemal Dolay Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Engin Dursun Atilla Elhan

İstanbul Çanakkale İstanbul Adana İstanbul İstanbul İstanbul Adana İstanbul İstanbul İstanbul İstanbul Antalya İstanbul Ankara Ankara İstanbul İstanbul İstanbul İstanbul İstanbul Elazığ İstanbul İstanbul Ankara Kırıkkale İstanbul Bursa İstanbul Edirne İstanbul Konya Kocaeli Erzurum İstanbul Ankara Edirne İstanbul Trabzon Erzurum İstanbul İstanbul İstanbul Edirne İzmir Adana İstanbul İstanbul Sakarya Antalya Antalya Düzce Bursa Ankara Ankara

Mehmet Eliçevik İmdat Elmas Ufuk Emekli Haluk Emir Yeşim Erbil Şevval Eren Hayri Erkol Metin Ertem Mehmet Eryılmaz Figen Esen Tarık Esen İrfan Esenkaya Ozlem Evren Kemer Nurperi Gazioğlu Fatih Ata Genç Alper Gökçe Niyazi Görmüş Feryal Gün Ömer Günal Nurullah Günay Haldun Gündoğdu Mahir Günşen Emin Gürleyik Hakan Güven Gökhan İçöz İbrahim İkizceli Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç Haluk Kiper Hikmet Koçak M Hakan Korkmaz Güniz Meyancı Köksal Cüneyt Köksoy İsmail Kuran Necmi Kurt Mehmet Kurtoğlu Nezihi Küçükarslan İsmail Mihmanlı Mehmet Mihmanlı Köksal Öner Durkaya Ören Hüseyin Öz Hüseyin Özbey Faruk Özcan Cemal Özçelik İlgin Özden Mehmet Özdoğan

İstanbul İstanbul İstanbul İstanbul İstanbul Diyarbakır Bolu İstanbul Ankara İstanbul İstanbul Malatya Ankara İstanbul İstanbul Tekirdağ Konya İstanbul Düzce Kayseri Ankara Adana Bolu İstanbul İzmir İstanbul İstanbul İzmir Bursa İstanbul Ankara İstanbul Bursa İstanbul Samsun Ankara Eskişehir Erzurum Ankara İstanbul Ankara İstanbul İstanbul İstanbul Ankara İstanbul Sakarya İstanbul Erzurum İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara

Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Volkan Öztuna Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Esra Can Say Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Remzi Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik Mustafa Tireli Alper Toker Rıfat Tokyay Salih Topçu Turgut Tufan Fatih Tunca Akif Turna Zafer Nahit Utkan Ali Uzunköy Erol Erden Ünlüer Özgür Yağmur Müslime Yalaz Serhat Yalçın Sümer Yamaner Mustafa Yandı Nihat Yavuz Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Konya Bursa İstanbul Ankara İstanbul Mersin İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul Tekirdağ İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa Balıkesir Adana İstanbul İstanbul İstanbul Trabzon İstanbul İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul İstanbul

ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD

Juan Asensio Zsolt Balogh Ken Boffard Fausto Catena Howard Champion Elias Degiannis Demetrios Demetriades Timothy Fabian Rafi Gürünlüoğlu Clem W. Imrie Kenji Inaba Rao Ivatury Yoram Kluger Rifat Latifi Sten Lennquist Ari Leppaniemi Valerie Malka Ingo Marzi Kenneth L. Mattox Carlos Mesquita

Miami, USA New Castle, Australia Johannesburg, S. Africa Bologna, Italy Washington DC, USA Johannesburg, S. Africa Los Angeles, USA Memphis, USA Denver, USA Glasgow, Scotland Los Angeles, USA Richmond, USA Haifa, Israel Tucson, USA Malmö, Sweden Helsinki, Finland Sydney, Australia Frankfurt, Germany Houston, USA Coimbra, Portugal

Ernest E Moore Pradeep Navsaria Andrew Nicol Hans J Oestern Andrew Peitzman Basil A Pruitt Peter Rhee Pol Rommens William Schwabb Michael Stein Spiros Stergiopoulos Michael Sugrue Otmar Trentz Donald Trunkey Fernando Turegano Selman Uranues Vilmos Vecsei George Velmahos Eric J Voiglio Mauro Zago

Denver, USA Cape Town, S. Africa Cape Town, S. Africa Celle, Germany Pittsburgh, USA San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece Liverpool, Australia Zurich, Switzerland Oregon, USA Madrid, Spain Graz, Austria Vienna, Austria Boston, USA Lyon, France Milan, Italy

REDAKSİYON (REDACTION) Erman Aytaç

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Başkan (President) Başkan Yardımcısı (Vice President) Genel Sekreter (Secretary General) Sayman (Treasurer) Yönetim Kurulu Üyeleri (Members)

Recep Güloğlu Kaya Sarıbeyoğlu Ahmet Nuray Turhan Hakan Yanar M. Mahir Özmen Ediz Altınlı Gürhan Çelik

İLETİŞİM (CORRESPONDENCE)

Ulusal Travma ve Acil Cerrahi Derneği İstanbul Üniversitesi İstanbul Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 34390 Çapa, İstanbul

Tel: +90 212 - 588 62 46 - 531 12 46 Faks (Fax): +90 212 - 533 18 82 e-posta (e-mail): travma@travma.org.tr Web: www.travma.org.tr

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi (Owner) Yazı İşleri Müdürü (Editorial Director) Yayın Koordinatörü (Managing Editor) Amblem Yazışma adresi (Correspondence address)

Tel Faks (Fax)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Deniz Abdal Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 531 09 39 +90 212 - 533 18 82

Abonelik: 2011 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (karepublishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Temmuz (July) 2012 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır.

Ulusal Travma ve Acil Cerrahi Dergisi, 2001 yılından itibaren Index Medicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası indekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsamındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır.

Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir.

Dergide Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir.

Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.

Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.

Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır.

Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır.

Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır.

Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler.

Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır.

Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir.

Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir.

Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir.

Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir.

Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir.

Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.

Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5.

It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.

Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.

Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials.

TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports.

Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/).

Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.

The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal.

It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” section, called “Upload Your Files”.

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

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Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 18

SAYI - NUMBER 4 TEMMUZ - JULY 2012

İçindekiler - Contents

Deneysel Çalışma - Experimental Study 283-288 Effects of hemoperitoneum on wound healing and fibrinolytic activity in colonic anastomosis Hemoperitoneumun kolon anastomozlarında yara iyileşmesine ve fibrinolitik aktivite üzerine etkisi

Köksal N, Uzun MA, Özkan ÖF, Kayahan M, İpçioğlu OM, Günerhan Y, Ergün E, Güneş P

Klinik Çalışma - Original Articles 289-295 The relationship of trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients Çoklu travmalı olgularda kalp enzimleri ve sitokinler ile travma şiddeti ve mortalitenin ilişkisi

Karakuş A, Kekeç Z, Akçan R, Seydaoğlu G 296-300 Burn unit: colonization of burn wounds and local environment Yanık ünitesi: Yanık yarası ve yerel çevresinde kolonizasyon

Essayagh T, Zohoun A, Tourabi K, Ennouhi MA, Boumaarouf A, Ihrai H, Elhamzaoui S 301-305 Cardiac monitoring in patients with electrocution injury Elektrik çarpması yaralanması olan hastalarda kardiyak monitörizasyon

Akkaş M, Hocagil H, Ay D, Erbil B, Kunt MM, Özmen MM 306-310 Toraks travması sonrası hayat kurtarıcı bir uygulama: Acil serviste torakotomi A life-saving approach after thoracic trauma: Emergency room thoracotomy

Akçam Tİ, Turhan K, Ergönül AG, Oğuz E, Çakan A, Çağırıcı U 311-316 Is total-subtotal colectomy and primary anastomosis a good treatment alternative in malignant obstructive lesions of the left colon?

Sol kolonun tıkayıcı malign lezyonlarında total-subtotal kolektomi ve primer anostomoz iyi bir tedavi alternatifi midir?

Arslan K, Eryılmaz MA, Okuş A, Doğru O, Karahan Ö, Köksal H 317-320 Delici göz küresi yaralanmalarından sonra fitizis bulbi gelişiminde etkili olan faktörler The factors affecting the development of phthisis bulbi after penetrating eye injuries

Coşkun M, Ataş M, Akal A, İlhan Ö, Keskin U, Tuzcu EA 321-327 Ocular trauma score in transferred fireworks-related ocular injuries: a case series Havai fişek taşımasında olan göz yaralanmalarında oküler travma skoru: Olgu serisi

Liu Y, Huang YF, Jiang JJ, Yu JF, Gong YB, Zhou XB, Du GP, Xu QQ 328-332 Are we prepared for orthopedic trauma surgery outside normal working hours?

A retrospective analysis Normal çalışma saatleri dışında ortopedik travma cerrahisi için hazır mıyız?

Retrospektif bir analiz

Al-Saflan MA, Azam MQ, Sadat-Ali M

Cilt - Vol. 18 Sayı - No. 4

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 18

SAYI - NUMBER 4 TEMMUZ - JULY 2012

İçindekiler - Contents

333-338 Management of inhalation injury and respiratory complications in Burns Intensive Care Unit Yanık yoğun bakım ünitesinde inhalasyon yaralanması ve solunum komplikasyonlarının yönetimi

Kabalak AA, Yastı AÇ 339-343 The impact of Ramadan on peptic ulcer perforation Peptik ülser perforasyonuna Ramazan’ın etkisi

Gökakın AK, Kurt A, Atabey M, Koyuncu A, Topçu Ö, Aydın C, Şen M, Akgöl G

Olgu Sunumu - Case Reports 344-346 Surgical treatment of a case with rapidly growing mass lesion after trauma: on the left forearm arteriovenous malformation Travma sonrası hızlı büyüyen kitlesi olan bir olgunun cerrahi tedavisi: Sol ön kolda arteriyovenöz malformasyon

Talay S, Erkut B, Kabalar ME 347-350 Cerebral infarction caused by traumatic carotid artery dissection Travmatik karotid arter diseksiyonuna bağlı serebral enfarktüs

Bayır A, Aydoğdu Kıreşi D, Söylemez A, Demirci O 351-354 Ileus due to Meckel’s diverticulum: case reports Meckel divertikülüne bağlı ileus: Olgu sunumları

Sözen S, Topuz Ö, Tükenmez M, Bilgin ÖF, Dönder Y 355-357 Bilateral asymmetric traumatic hip dislocation with bilateral acetabular fracture: case report İki taraflı asimetrik travmatik kalça çıkığı ve iki taraflı asetabulum kırığı: Olgu sunumu

Olcay E, Adanır O, Özden E, Barış A 358-360 Perforation of Meckel’s diverticulum by a button battery: Report of two cases Düğme pilin neden olduğu Meckel divertikülü perforasyonu: İki olgu sunumu

Özokutan BH, Ceylan H, Yapıcı S, Sımsık S 361-363 Subcutaneous emphysema and pneumomediastinum complicating a dental procedure Dental işlemin komplikasyonu olarak gelişen cilt altı amfizemi ve pnömomediasten

Döngel İ, Bayram M, Uysal İÖ, Sunam GS 364-366 Late-onset spinal accessory nerve palsy after traffic accident: case report Trafik kazası sonrasında geç gelişen spinal aksesuvar sinir lezyonu: Olgu sunumu

Tekin T, Ege T

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):283-288

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2012.65289

Effects of hemoperitoneum on wound healing and fibrinolytic activity in colonic anastomosis Hemoperitoneumun kolon anastomozlarında yara iyileşmesine ve fibrinolitik aktivite üzerine etkisi Neşet KÖKSAL,1 Mehmet Ali UZUN,2 Ömer Faruk ÖZKAN,2 Münire KAYAHAN,2 Osman Metin İPÇİOĞLU,3 Yusuf GÜNERHAN,1 Ersin ERGÜN,2 Pembegül GÜNEŞ4 BACKGROUND

AMAÇ

We aimed to test whether hemoperitoneum has adverse effects on colonic anastomosis healing by increasing fibrinolytic activity.

Kolon anastomozlarında iyileşme ve fibrinolitik aktivite üzerine hemoperitoneumun etkisi araştırıldı.

METHODS

Wistar Albino cinsi 20 sıçanda, kolon kesilip anastomoz yapıldıktan sonra 10 sıçana (Grup 1) karın içine verici sıçanlardan alınan kan (25 ml/kg), 10 sıçana (Grup 2) ise serum fizyolojik verildi. Sıçanlar beşinci gün sakrifiye edilerek anastomoz patlama baçınçları ölçüldü. Anastomoz hattının histopatolojik değerlendirilmesi yapılarak, omentum, akciğer ve anastomoz hattında hidroksiprolin, doku plazminojen aktivatörü (tPA), plazminojen aktivatör inhibitörü-1 (PAI 1) ve tPA/PAI 1 kompleksi düzeyleri saptandı.

After colonic intersection and anastomosis, 20 Wistar Albino rats received intraabdominal injections of either 25 mg/ kg blood (10, Group 1) or physiologic saline (10, Group 2).

Anastomotic bursting pressures were measured after sacrifice on the fifth day. Following histopathological evaluation of the anastomotic line, hydroxyproline, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and tPA/PAI-1 complex levels were determined in the omentum, lung and anastomotic colon.

RESULTS

GEREÇ VE YÖNTEM

BULGULAR

Mean anastomotic bursting pressures of Groups 1 and 2 were 224.5 mmHg and 254.4 mmHg (p=0.121), and mean hydroxyproline levels were 45.89 and 65.959 mg/g protein, respectively (p=0.257). Histopathology was insignificant.

There was a significant difference between groups in omental tPA levels (0.962 ng/ml and 0.27 ng/ml, p=0.041), but not in PAI-1 and tPA/PAI-1. Anastomotic line and lung levels of tPA, PAI-1 and tPA/PAI-1 complex were not significantly different between groups. The relation between anastomotic line tPA level and bursting pressure was highly significant in Group 2 (r=0.778; p=0.008).

Anastomoz patlama basıncı Grup 1’de 224,5 mmHg, Grup 2’de 254,4 mmHg idi (p=0,121). Hidroksiprolin değerleri Grup 1 ve Grup 2’de sırasıyla 45,89 ve 65,959 mg/gr protein olarak bulundu (p=0,257). Histopatolojik incelemede anlamlı farklılık saptanmadı. Omentum tPA değeri Grup 1’de 0,962 ng/ml, Grup 2’de 0,27 ng/ml olup, fark anlamlı idi (p=0,041). Omentum PAI 1 ve tPA/PAI 1 kompleksi değerleri, anastomoz ve akciğer dokuları tPA, PAI 1 ve tPA/PAI 1 kompleksi değerleri açısından gruplar arasındaki fark anlamlı değildi. Grup 2’de anastomoz hattı tPA değeri ile anastomoz patlama basıncı arasındaki ilişki yüksek düzeyde anlamlı idi (r=0,778; p=0,008).

CONCLUSION

SONUÇ

In this first study on the effect of hemoperitoneum on colonic anastomosis, we observed no significant effect on anastomotic healing or fibrinolytic activity, except in the omentum. Further studies with different blood volumes and assessment times are needed.

Kolon anastomozlarında hemoperitoneumun etkisini araştıran bu ilk çalışmada, anastomoz iyileşmesinde ve omentum haricinde fibrinolitik aktivitede anlamlı fark gözlenmedi. Farklı kan volümleri ve farklı değerlendirme zamanları ile yapılacak yeni çalışmalara ihtiyaç vardır.

Key Words: Colonic anastomosis; fibrinolysis; hemoperitoneum; wound healing.

Anahtar Sözcükler: Kolon anastomozu; fibrinolizis, hemoperitoneum; yara iyileşmesi.

Department of General Surgery, Kafkas University Faculty of Medicine Kars; Departments of 22nd General Surgery, 4Pathology, Haydarpasa Numune Training and Research Hospital, Istanbul; 3Biochemistry and Clinical Biochemistry Unit, GATA Haydarpasa Training Hospital, Istanbul, Turkey.

1

Kafkas Üniversitesi Tıp Fakültesi, Genel Cerrahi Kliniği, Kars; Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 2 2. Genel Cerrahi Kliniği, 4Patoloji Kliniği, İstanbul; 3 GATA Haydarpaşa Eğitim Hastanesi, Biyokimya ve Klinik Biyokimya Birimi, İstanbul.

1

Correspondence (İletişim): Mehmet Ali Uzun, M.D. Hamidiye Mah. Gürbüz Sok., Bolelli Çamlık Evleri-2 Sitesi, B Blok D: 12, Çekmeköy 34782 İstanbul, Turkey.

Tel: +90 - 216 - 542 32 32-1531 e-mail (e-posta): mauzun@ttmail.com

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Anastomotic leakage after colon resection remains a significant problem and a major cause of postoperative morbidity and mortality. In large series, it has been reported to be associated with 25-37% of deaths.[1] Intraabdominal hemorrhage is the other complication that can develop during and/or after the operation. Its effects on hemodynamics and tissue perfusion are well known and appropriately struggled with. However, the potential effects of hemoperitoneum on colonic anastomosis healing have been neglected.

Yamamoto et al.[2] demonstrated that hemoperitoneum caused an increase in fibrinolytic activity. Increased fibrinolytic activity was also reported to result in adverse effects on wound healing.[3-5] In this study, we aimed to analyze whether hemoperitoneum caused unwanted effects on wound healing in colonic anastomosis by increasing fibrinolytic activity.

MATERIALS AND METHODS With the approval of the local Ethics Committee, this study was conducted in the Experimental Research and Animal Laboratory of Haydarpasa Numune Training and Research Hospital by investigators from the Second Department of General Surgery.

Histopathological examinations were performed in the Pathology Unit of Haydarpasa Numune Training and Research Hospital. Photometric and enzyme-linked immunosorbent assay (ELISA) measurements were done in the Biochemistry Unit of GATA Haydarpasa Training Hospital.

In this experimental study, 30 female Wistar Albino rats were used. Rats were housed at 24°C with a 12hour (h) light-dark cycle. The average weight of the 20 rats used for the experiment was 210 g (range: 180260 g). Ten more rats were used as donors. Anesthesia was achieved with intraperitoneal administration of 75 mg/kg ketamine HCl (Ketalar® Flacon; Pfizer Pharmaceutical Co, Istanbul, Turkey) and 10 mg/kg xylazine HCl (Basilazin Flacon; Bavet Drug Co, Istanbul, Turkey). Laparotomy was performed through a 3-cm midline incision. The descending colon was intersected completely at a level 3 cm proximal to the peritoneal reflection. An inverted single-layer end-to-end anastomosis was constructed with eight interrupted sutures with 6/0 polypropylene (ProleneTM). After completion of the anastomosis, hemoperitoneum was formed in 10 randomly chosen rats (Group 1: hemoperitoneum group) with 25 ml/kg blood given intraperitoneally, which was obtained from donor rats through the intracardiac route and then cross-matched.

The remaining 10 rats received 25 ml/kg physiologic saline, intraperitoneally, following completion of the anastomosis (Group 2: control group). Laparot284

omy incisions were closed in two layers with continuous 3/0 silk sutures. All the rats were sacrificed on the postoperative fifth day with laparotomy. Inspection for anastomotic dehiscence and local peritonitis, which was defined as the macroscopic sign of inflammation, and hypervascularity was performed. The colon was occluded 2 cm proximal to the anastomosis through ligation with a 3/0 silk. The tip of a cannula, the outer end of which was connected to a volume-directed infusion pump filled with physiologic saline, was inserted into the anal canal and pushed forward to the lumen of the anastomosis. A perianal circular suture with 3/0 silk was ligated to fix the cannula. The side arm of the cannula was connected to a pressure transducer, which in turn was connected to a monitor. The occluded colonic segment was gradually filled with physiologic saline at a constant rate of 150 ml/h while the intraluminal pressure was monitored until burst occurred, as indicated as an abrupt loss of pressure. The bursting pressures (BPs) were documented.

The 1-cm colonic segment containing the anastomosis was excised and opened longitudinally, and after being washed under physiologic saline, was blotted. The region of anastomosis was separated into three longitudinal pieces with a knife. Two pieces were placed into the Eppendorf tubes and frozen at -80°C, while the other was put into formol for histopathological evaluation. Tissue samples obtained from the omentum and lungs by thoracotomy were blotted again after being washed with physiologic saline.

They were also placed into Eppendorf tubes and frozen at -80°C. Histopathological examination of the line of anastomosis was performed by the same pathologist, who was blinded to the groups. Each side was examined and evaluated by grading based on the presence of erythrocytes, polymorphonuclear cells, mononuclear cells, fibroblasts, collagen fibers, and fibrin, as follows: 0 for no evidence, 1 for occasional evidence, 2+ for light scattering, 3+ for abundance, and 4+ for confluence of cells or fibers, as described previously.[6] Hydroxyproline, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1) and tPA/PAI-1 complex levels were measured at the line of anastomosis. Levels of tPA, PAI-1 and tPA/PAI-1 complex were also determined in the omentum for intraabdominal fibrinolytic activity and in lung tissue for the systemic fibrinolytic activity.

Biochemical Analysis After measurement of dry weights of the samples, they were buffered with potassium phosphate and placed in homogenizers (Ultra-Turrax T-25 model, Janke&Kugel, Staufen, Germany) at 1000 U for 3 minutes (min) in order to obtain homogeneity as 1 Temmuz - July 2012

Effects of hemoperitoneum on colonic anastomosis healing

Table 1. Comparison of mean anastomotic bursting pressures and hydroxyproline values of the groups

Bursting pressure (mmHg) Hydroxyproline (mg/g protein)

Group 1 Mean±SD

Group 2 Mean±SD

p

224.5±65.389 45.89±28.324

254.4±63.325 65.959±30.706

0.121 0.257

Table 2. Summary of histological examination of the anastomosis lines

Parameter Erythrocytes Polymorphonuclear cells Mononuclear cells Fibroblasts Collagen fibers Fibrin

Group 1 Mean±SD

Group 2 Mean±SD

p

0.575±0.442 1.7±0.654 1.575±0.667 1.825±0.764 0.775±0.546 1.225±0.702

0.7±0.587 1.375±0.592 1.65±0.615 1.85±0.679 1.25±0.391 0.925±0.678

0.812 0.134 0.619 0.879 0.051 0.213

ml/70 mg dry weight tissue. Then, they were placed in a sonicator (Bandelin Electronic, Berlin, Germany) for 30 min. Homogenates obtained at the end of this period were centrifuged at +4°C for 10 min at 6000 g with formation of supernatants. Levels of fibrinolytic components were measured in prepared tissue extracts. For determination of tPA, PAI-1 and tPA/PAI1 complex levels in the supernatants, micro ELISA method was used (ASSAYPRO® Plasma tPA ELISA, Universal Biologicals (Cambridge) Ltd., Cambridge, UK). Absorbance values were determined by KaytoMicroplate Reader RT 2100 C (Fayto Electronic Inc., China). Standard lines were drawn, with the absorbance values measured corresponding to standard concentrations. Concentrations of tPA, PAI-1 and tPA/ PAI-1 complex were calculated by placing the absorbance values in the formula of the linear equation.

Protein content of the tissue samples was measured

by Lowry method.[7] Results of tPA, PAI-1 and tPA/ PAI-1 complex were expressed as ng/mg protein. The procedure for the measurement of hydroxyproline was based on alkaline hydrolysis of the tissue homogenate and subsequent determination of free hydroxyproline in hydrolysates.[7] Chloramine-T was used to oxidize free hydroxyproline for the production of a pyrrole.

With the addition of Ehrlich’s reagent, a chromophore was produced that can be measured at 550 nm. Optimal assay conditions were determined using tissue homogenate and purified acid soluble collagen along with standard hydroxyproline.[8] Results were calculated as µg/mg.

Statistical Analysis The Statistical Package for the Social Sciences (SPSS) program for Windows 15.0 was used for staCilt - Vol. 18 Sayı - No. 4

tistical analysis. For evaluation of the data, descriptive statistical methods (mean, standard deviation) were used together with Mann-Whitney U test for comparison of quantitative data, chi-square test for comparison of qualitative data, and Pearson’s correlation for the search of the relationship between variables. Results were evaluated within 95% confidence interval, and values of p<0.05 were accepted as significant.

RESULTS No anastomotic dehiscence or local peritonitis was detected in any of the rats sacrificed. Hydroxyproline levels of the anastomotic line and BP measured to evaluate wound healing in anastomosis are shown in Table 1 and histopathological findings of the anastomotic line in Table 2. Mean BP was 224.5 mmHg in Group 1 and 254.4 mmHg in Group 2 (p=0.121). Mean hydroxyproline levels of Groups 1 and 2 were 45.89 and 65.959 mg/g protein, respectively (p=0.257).

There were no significant histopathological differences between groups.

Levels of tPA, PAI-1 and tPA/PAI-1 complex determined to evaluate the fibrinolytic activity in the anastomotic line, omentum and lung tissue of each group are reported in Table 3.

Omental tPA value was 0.962 ng/ml in Group 1 and 0.27 ng/ml in Group 2, and the difference was statistically significant (p=0.041); however, there was no significant differences between the two groups regarding the other parameters. Among the relationships between all values measured, only the relation between tPA levels of the anastomotic line and anastomotic BP in Group 2 was highly significant (r=0.778; p=0.008).

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Table 3. Levels of tPA, PAI-1 and tPA/PAI-1 complex in the anastomotic line, omentum and lung tissue of the groups

Anastomotic line

Group 1

Group 2

p Omentum

Group 1

Group 2

p Lung tissue

Group 1

Group 2

p

tPA (ng/ml) Mean±SD

PAI-1 (ng/ml) Mean±SD

tPA/PAI-1 complex (ng/ml) Mean±SD

1.531±0.932 0.96±0.695 0.112

0.924±0.304 2.3±2.857 0.290

0.862±0.157 0.844±0.166 0.762

0.962±1.02 0.27±0.151 0.041

2.351±2.779 3.341±3.718 0.999

0.726±0.247 0.561±0.147 0.151

2.025±1.197 1.797±1.12 0.450

1.947±1.372 2.178±2.917 0.364

0.735±0.088 0.843±0.298 0.596

DISCUSSION The effect of hemoperitoneum on fibrinolytic activity was investigated by Yamamoto et al.[2] In their study, 100 ml/kg blood obtained from donor rats was given to the rats of the hemoperitoneum group, intraperitoneally, while the control group received the same amount of physiologic saline. The rats were sacrificed on the fourth day, and in the hemoperitoneum group, fibrinolytic activity was found to be increased significantly in the omentum and lung tissue, which reflected the local and systemic fibrinolytic activity, respectively. They connected these results with the development of re-bleeding in patients with blunt trauma who were followed up or treated without operation, and this had been the starting point for our hypothesis. For the determination of fibrinolytic activity, we used tPA, PAI1 and tPA/PAI-1 complex values instead of the fibrin plate method used by those authors. tPA is the main plasminogen activator and its activity is restricted by plasminogen activating inhibitors, predominantly PAI1. They come together to form inactive complexes that limit the activity of tPA and therefore the fibrinolytic activity.

There is a covariance between PAI-1 and tPA/PAI1 complex values.[9,10] In our study, omental PAI-1 and tPA/PAI-1 complex values did not vary significantly between Group 1 and Group 2, but tPA values were significantly higher in Group 1 than Group 2. This can be interpreted as indicating that hemoperitoneum increases the fibrinolytic activity in the omentum. The fibrinolytic activity parameters determined in the anastomotic line for the effect on anastomosis and in lung tissue for the systemic effect revealed that although tPA values of Group 1 were higher than those of Group 2, there was no significant difference between the groups 286

for either tPA values or for tPA/PAI-1 complex values.

Our findings of increased fibrinolytic activity in the omentum were consistent with the results obtained by Yamamoto et al.,[2] but we could not demonstrate the same finding in lung tissue. When comparing the results, the differences in blood volume used to produce hemoperitoneum and in time to assessment should be kept in mind. We used less blood (25 ml/kg versus 100 ml/kg) in order to decrease the number of donor rats used, and sacrificed rats at a later time (5 days versus 4 days) to evaluate synchronous wound healing of the anastomoses.

In the literature, fibrinolytic activity was assessed more commonly in studies evaluating development of intraabdominal adhesions, and different results at different assessment times were reported.[11-14] In those studies, peritoneal fluid and peritoneal samples with adhesive tissues were generally used, which do not match with our experimental model.

Several factors can influence the healing process in colonic anastomosis. Preoperative factors include gender, malnutrition (anemia, hypoalbuminemia), weight loss, and cardiovascular disease, while surgeryrelated factors include long operation time, intraoperative blood loss requiring multiple blood transfusions, intraoperative contamination of the operative field, level of the anastomosis, adequate tissue perfusion in anastomosis, tension-free anastomosis, and the surgeon’s experience in colorectal surgery.[15,16] The effect of hemoperitoneum, however, has not been searched yet, and our study is the first in this field.

The extracellular matrix (ECM), in particular the collagen metabolism and its potential disturbance, is an important factor influencing the outcome of anastomotic healing in the intestines.[17,18] The matrix metalTemmuz - July 2012

Effects of hemoperitoneum on colonic anastomosis healing

loproteinases (MMPs), which are structurally related neutral proteinases, can degrade almost all ECM components and play an important role in wound healing and remodeling of the ECM.[19] In animal experiments and a clinical research, a direct correlation between increased MMP expression and anastomotic leakage was demonstrated.[5,20] Plasmin and tissue activator of plasminogen, which act as structural elements of the fibrinolytic activity, contribute to the activation of collagenase (MMP-1), resulting in increased degradation of ECM proteins, such as collagen.[4] Thrombin-activatable fibrinolysis inhibitor (TAFI) is a procarboxypeptidase that is synthesized in the liver. Activated TAFI can downregulate fibrinolysis by removing carboxyterminal lysines from fibrin, which act as binding sites for plasminogen and tPA. In a pulmonary clot lysis model, it was demonstrated that fibrinolysis was significantly increased in TAFI knockout rats.[21] te Velde et al.[3] demonstrated that wound healing was disturbed both in cutaneous wounds and colonic anastomosis in mice lacking TAFI, and they concluded that it was due to the increased fibrinolytic activity resulting in unbalanced matrix degradation.

In addition to those findings supporting our hypothesis, Cohen et al.[22] administered single-dose infusion of neurokinin-1 receptor antagonist intraperitoneally during and 1, 5, 12, and 24 h after the operation.

They measured peritoneal tPA activity at 24 h after the procedure, and observed the adhesion formation and anastomotic BP 7 days after the operation. Increase in peritoneal tPA activity was associated with a decrease in adhesion formation in 1- and 5-h trials, but in the 12-h trial, there was no difference in either tPA activity or adhesion formation. No significant decrease was recorded in the anastomotic BP in either group, and this could be because of administration of neurokinin-1 receptor antagonist at an early phase and as a single dose. In our study, there was a highly significant relationship between the anastomotic line tPA value and the BP in Group 2, but the relation could not be demonstrated in Group 1.

Both the anastomotic BPs and the hydroxyproline levels of Group 1 were lower than in Group 2, but the difference was not statistically significant in this study.

On histopathological evaluation of the anastomoses, no significant difference was observed between the groups, and as collagen typing was not performed, the data were not suitable for interpretation for ECM changes.

In conclusion, the tendencies in the parameters of both the fibrinolytic activity and wound healing in anastomosis obtained in our study are encouraging with respect to our hypothesis, but future studies performed with different blood volumes and evaluation times are required.

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REFERENCES 1. Kanellos I, Blouhos K, Demetriades H, Pramateftakis MG, Mantzoros I, Zacharakis E, et al. The failed intraperitoneal colon anastomosis after colon resection. Tech Coloproctol 2004;8:53-5.

2. Yamamoto Y, Wakabayashi G, Ando N, Aikawa N, Kitajima M. Increased fibrinolytic activity and body cavity coagula.

Surg Today 2000;30:778-84.

3. te Velde EA, Wagenaar GT, Reijerkerk A, Roose-Girma M, Borel Rinkes IH, Voest EE, et al. Impaired healing of cutaneous wounds and colonic anastomoses in mice lacking thrombin-activatable fibrinolysis inhibitor. J Thromb Haemost 2003;1:2087-96.

4. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999;341:738-46.

5. Stumpf M, Klinge U, Wilms A, Zabrocki R, Rosch R, Junge K, et al. Changes of the extracellular matrix as a risk factor for anastomotic leakage after large bowel surgery. Surgery 2005;137:229-34.

6. Ehrlich HP, Tarver H, Hunt TK. Effects of vitamin A and glucocorticoids upon inflammation and collagen synthesis. Ann Surg 1973;177:222-7.

7. Lowry OH, Rosebrough NJ, Farr AL, Randall RJ.. Protein measurement with the Folin phenol reagent. J Biol Chem 1951;193:265-75.

8. Reddy GK, Enwemeka CS. A simplified method for the analysis of hydroxyproline in biological tissues. Clin Biochem 1996;29:225-9.

9. Reijnen MM, Holmdahl L, Kooistra T, Falk P, Hendriks T, van Goor H. Time course of peritoneal tissue plasminogen activator after experimental colonic surgery: effect of hyaluronan-based antiadhesive agents and bacterial peritonitis.

Br J Surg 2002;89:103-9.

10. Ivarsson ML, Bergström M, Eriksson E, Risberg B, Holmdahl L. Tissue markers as predictors of postoperative adhesions. Br J Surg 1998;85:1549-54.

11. Neudecker J, Junghans T, Raue W, Ziemer S, Schwenk W. Fibrinolytic capacity in peritoneal fluid after laparoscopic and conventional colorectal resection: data from a randomized controlled trial. Langenbecks Arch Surg 2005;390:5237.

12. Hellebrekers BW, Trimbos-Kemper GC, Bakkum EA, Trimbos JB, Declerck PJ, Kooistra T, et al. Short-term effect of surgical trauma on rat peritoneal fibrinolytic activity and its role in adhesion formation. Thromb Haemost 2000;84:87681.

13. Tarhan OR, Barut I, Sutcu R, Akdeniz Y, Akturk O. Pentoxifylline, a methyl xanthine derivative, reduces peritoneal adhesions and increases peritoneal fibrinolysis in rats. Tohoku J Exp Med 2006;209:249-55.

14. Akdeniz Y, Tarhan OR, Barut I. Can dexpanthenol prevent peritoneal adhesion formation? An experimental study. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2007;13:94100.

15. Mäkelä JT, Kiviniemi H, Laitinen S. Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 2003;46:653-60.

16. Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 1998;85:355-8.

17. Jiborn H, Ahonen J, Zederfeldt B. Healing of experimental colonic anastomoses. IV. Effect of suture technique on collagen metabolism in the colonic wall. Am J Surg 1980;139:40613.

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18. Braskén P, Renvall S, Sandberg M. Fibronectin and collagen gene expression in healing experimental colonic anastomoses. Br J Surg 1991;78:1048-52.

19. Ravanti L, Kähäri VM. Matrix metalloproteinases in wound repair (review). Int J Mol Med 2000;6:391-407.

20. Savage FJ, Lacombe DL, Boulos PB, Hembry RM. Role of matrix metalloproteinases in healing of colonic anastomosis.

Dis Colon Rectum 1997;40:962-70.

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21. Swaisgood CM, Schmitt D, Eaton D, Plow EF. In vivo regulation of plasminogen function by plasma carboxypeptidase B. J Clin Invest 2002;110:1275-82.

22. Cohen PA, Aarons CB, Gower AC, Stucchi AF, Leeman SE, Becker JM, et al. The effectiveness of a single intraperitoneal infusion of a neurokinin-1 receptor antagonist in reducing postoperative adhesion formation is time dependent. Surgery 2007;141:368-75.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):289-295

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.81488

The relationship of trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients Çoklu travmalı olgularda kalp enzimleri ve sitokinler ile travma şiddeti ve mortalitenin ilişkisi Ali KARAKUŞ,1 Zeynep KEKEÇ,2 Ramazan AKÇAN,3 Gülşah SEYDAOĞLU4 BACKGROUND

AMAÇ

In this study, we aimed to determine the effects of trauma severity on cardiac involvement through evaluating the trauma severity score together with diagnostic tests in multiple trauma patients. A trauma score was determined using various trauma severity scales.

Çalışmamızda çeşitli travma şiddet ölçekleriyle zedelenme oranlarını belirlediğimiz çoklu travma hastalarında; bu şiddet oranlarının kalp etkilenimi üzerine etkilerini yardımcı tanı araçları ile birlikte değerlendirerek kıyaslamayı hedefledik.

METHODS

GEREÇ VE YÖNTEM

After obtaining the approval of the ethics committee of the faculty, this prospective study was performed through evaluating 100 multiple trauma patients, aged over 15 years, who applied to our Emergency Department (ED). After determining the trauma severity score using instruments such as the Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS), the cardiac condition was evaluated using biochemical and radiological diagnostic tests.

İleriye dönük olarak planlanan bu çalışma, fakülte etik kurul onayı alındıktan sonra acil servise başvuran 15 yaşın üzerinde çoklu travmalı 100 hasta değerlendirilerek yapıldı.

Hastalarda yaralanma şiddeti ölçeği (ISS), Glaskow koma skalası (GCK), revize edilmiş travma skoru (RTS) gibi travma şiddet ölçekleri kullanılarak travmanın şiddeti belirlendikten sonra, biyokimya ve radyolojik tanı araçlarından faydalanılarak kalp etkilenimi değerlendirildi.

RESULTS

BULGULAR

During the study period, 100 patients were evaluated (78 male, 22 female; mean age: 33.2±15.4; range 15 to 70 years). It was determined that 92 (92%) were blunt trauma cases, and 77 (77%) of them were due to traffic accidents.

The majority of cases showed electrocardiogram (ECG) abnormalities (63%) and sinus tachycardia (36%). Abnormal echocardiogram (ECHO) findings, mostly accompanied by ventricular defects (n=24), were determined in 31 of the cases. Nineteen cases with high trauma severity score resulted in death, and 14 of all deaths were secondary to traffic accidents. Trauma scores were found to show a significant difference between the two groups.

Çalışma süresince 100 hasta (78 erkek, 22 kadın; ortalama yaş 33; dağılım 15-70 yaş) değerlendirildi. Çoklu travma hastalarının 92’sinin (%92) künt travma, bunlardan da 77’sinin (%77) trafik kazası sonucu olduğu belirlendi.

Hastaların %63’ünde çoğunluğu sinüs taşikardisi (%36) olan elektrokardiyogramda (EKG) bozukluğu bulgusu görüldü. Olguların 31’inde çoğunluğunu ventrikül işlev bozukluğunun (n=24) oluşturduğu anormal ekokardiyogram (EKO) bulguları saptandı. Travma şiddeti yüksek olan 19 olgunun 14’ü trafik kazası nedeniyle hayatını kaybetti. İki grup arasında travma skorları istatistiksel olarak anlamlıydı.

CONCLUSION

SONUÇ

The ISS trauma scale was determined to be the most effective in terms of indicating heart involvement in patients with multiple traumas. Close follow-up and cardiac monitoring should be applied to patients with high trauma severity scores considering possible cardiac rhythm changes and hemodynamic disturbances due to cardiac involvement.

Çoklu travma hastalarında kalp etkilenimini en iyi gösteren travma ölçeğinin ISS olduğu belirlendi. Yüksek travma şiddetine sahip çoklu travmalı hastalara, kalp etkilenimi olabileceği düşünülerek, kalp ritm bozukluğu ve hemodinamik bozukluk açısından kalp monitörizasyonu ve yakın takip yapılmalıdır.

Key Words: Cardiac involvement; cardiac markers; multiple trauma; trauma severity scales.

Anahtar Sözcükler: Kalp etkilenimi; kalp belirteçleri; çoklu travma; travma şiddet ölçekleri.

Department of Emergency Medicine, Mustafa Kemal University Faculty of Medicine, Hatay; Departments of 2Emergency Medicine, 4Biostatistics, Cukurova University Faculty of Medicine, Adana; 3Department of Forensic Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.

1

Mustafa Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Hatay; Çukurova Üniversitesi Tıp Fakültesi, 2Acil Tıp Anabilim Dalı, 4Biyoistatistik Anabilim Dalı, Adana; 3Hacettepe Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı, Ankara.

1

Correspondence (İletişim): Ali Karakuş, M.D. Mustafa Kemal Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, 31100 Hatay, Turkey.

Tel: +90 - 326 - 245 51 14 e-mail (e-posta): drkarakus@yahoo.com

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The term multiple trauma describes trauma-related damage involving multiple body cavities or body parts. Being among the leading causes of death and responsible for high morbidity and mortality rates, multiple traumas constitute an important public health problem.[1] In our country, 111,565 beating cases and 929,304 traffic collisions resulting in death (4228 cases) and injury (183,841 cases) were recorded in 2008.

It is known that one-third of hospitalized cases are due to chest trauma, which is responsible for 20-25% of multiple trauma-related deaths.[1,2] In order to determine and treat cardiac rhythm changes in multiple trauma patients in the early period, frequent examination and close follow-up with cardiac monitoring are of high importance. Troponin T (TnT) and troponin I (TnI) are regarded as the featured indicators in slight cardiac injuries.[3,4] Changes in levels of tumor necrosis factor (TNF)-alpha might be determined due to myocyte damage secondary to cardiac spasm-traumatic cardiac injuries.[5] Ideal trauma grading systems should target the correct definition of all damage and the severity of each type of damage. Additionally, it should be applicable with acceptable features in trauma centers.

MATERIALS AND METHODS Multiple trauma patients (n=100) admitted to Cukurova University, Faculty of Medicine, Emergency Department (ED) were included in the scope of this prospective clinical study. Approval of the ethical committee and informed consent of each case were obtained.

During the study period, the total number of patients admitted to Cukurova University ED was 28,033, while the number of all patients with trauma was 1,108 (3.95%). Of these, 100 patients with multiple trauma with involvement of at least two body parts were included in the scope of the study.

In the present study, Injury Severity Score (ISS) and Revised Trauma Score (RTS) were used to determine trauma severity; Glasgow Coma Scale (GCS) was used to determine consciousness. The patients were divided into two groups using critical values of each scale as severe or slight traumatic injury. The critical value for ISS was accepted as 15, for RTS 11, and for GCS 8.

Normal values were regarded as <170 U/L. TnT: Electrochemiluminescence immunoassay (ECLIA) analyzers, Modular Analytics E170 (Elecsys module) and Roche Elecsys 2010 method were used.

Normal values were regarded as <0.1 ng/ml.

TNF-alpha: TNF-alpha was studied with Micro Elisa method and Biosorc (Belgium) mark kits. Normal values were regarded as 0.4-3.6 pg/ml.

Echocardiogram (ECHO): The patients were evaluated using ECHO and mobile ECHO Device 3.5 megahertz probe in the Cardiology Laboratory.

Statistical Analysis In order to analyze the permanent factors, Spearman correlation test and Mann-Whitney U tests were used. While analyzing the categorical factors, chisquare test was used. A p value of <0.05 was accepted as statistically significant. The data was summarized as mean, ± standard deviation (SD) and median (minimum-maximum). Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows package software version 13.0.

RESULTS During the study period, of 1108 trauma patients admitted to our ED, 829 were male and 279 were female, with a mean age of 32 years and a male/female ratio of 2.9. Of those patients, 100 had multiple traumas. Of these, 78 patients were male and 22 were female, with a male to female ratio of 3.5. Patients’ ages ranged between 15 and 70 years, with an average age of 33.2±15.4 years.

Of all cases, 3 patients had previous trauma history while 4 suffered from cardiac failure. Additionally, the medical history of patients revealed that 2 had previous myocardial infarction, 1 had arrhythmia and another had both arrhythmia and cardiac failure.

Examining these cases, abnormal electrocardiogram (ECG), CK-MB, CK, and CK-MB/CK were found in 4 patients, ECHO and TnT were abnormal in 3 patients and TNF-alpha was abnormal in 1 patient. The ECG and ECHO results are shown in Table 1.

Creatine kinase-MB fraction (CK-MB): Electrochemiluminescence immunoassay (ECLIA) analyzers, Modular Analytics E170 (Elecsys module) and Roche Elecsys 1010/2010 method were used. Normal range was regarded as 0.97-4.94 ng/ml.

ECG was abnormal in 63 patients and normal in the remaining 37 patients. The most common finding was sinus tachycardia, followed by right branch block.

ST-T wave change, a finding that might indicate myocardial damage, was seen in 10 patients. Of these 10 cases revealing ST-T changes, ECHO revealed abnormal findings in 4 patients (functional defect of ventricles and pericardial effusion); CK-MB levels were abnormal in 7 patients, while TnT and TNF-alpha were abnormal in 4 patients. Furthermore, abnormal CK-MB/CK ratio was detected in all 10 patients.

CK: Roche/Hitachi: ACN 057 method was used.

Examining ECHO results, findings were normal

Cardiologic Evaluation

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Trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients

Table 1. Distribution of abnormal ECG and ECHO findings of patients Abnormal ECG findings

Number of Patients (n)

Arrhythmia Sinus tachycardia Sinus bradycardia Damage of heart muscle ST-T wave disorders Conduction system disorders Right bundle block Total Abnormal ECHO findings Pleural effusion Pericardial effusion Ventricular wall motion abnormality Pericardial effusion + cardiac muscular laceration Pericardial effusion + left ventricular wall motion abnormality Cardiac valve disorders + left ventricular wall motion abnormality Interventricular septum wall motion abnormality Total

36 4 10 13 63 n 2 1 20 1 1 3 3 31

Table 2. Accompanying injuries and abnormal findings Diseases

Pulmonary contusion Hemothorax Isolated pneumothorax Hemopneumothorax Sternum fracture Scapula fracture Clavicle fractures Rib fractures 1st, 2nd and 3rd rib fractures Flail chest

Number of Abnormal Abnormal Abnormal Abnormal Patients ECG ECHO TnT CK-MB 13 3 1 3 3 4 8 21 9 10

in 65 patients, and of the remaining, abnormal findings were detected in 31 patients. The most common abnormal finding on ECHO was ventricular function defect. ECG findings were also abnormal in 19 of those 31 cases with abnormal ECHO. Of these 31 cases, CK-MB/CK, CK-MB, TNF-alpha, and TnT were abnormal in 17, 13, 5, and 4 cases, respectively. Furthermore, according to ISS, 16 patients with abnormal ECHO findings were in the severely damaged group.

Of 65 patients with normal ECHO, 37 showed abnormal ECG, 64 had abnormal CK levels, and 60 showed abnormal CK-MB/CK. Abnormal levels of CK-MB, TNF-alpha and TnT were detected in 45, 30 and 5 patients, respectively. The relationship of accompanying injuries and abnormal findings is shown in Table 2.

The relationship between trauma scales and cardiac markers, admission-hospitalization, and discharge Cilt - Vol. 18 Sayı - No. 4

12 3 1 3 1 1 2 12 4 4

3 2 1 1 3 1 – 13 2 6

1 2 – – – – – 4 1 1

5 – – – 3 – 2 8 8 5

periods is shown in Table 3. The hospitalization period was prolonged in parallel to an extended period before presentation to the hospital. A positive correlation was determined between the hospitalization period and ISS, GCS and RTS; with increasing trauma severity, the hospitalization period was also increased.

Additionally, ISS increased in conjunction with extending duration before presentation. Evaluating the relationship of cardiac markers and trauma score, it was determined that TnT, CK-MB and CK showed a positive correlation with ISS, while a negative correlation was determined between TnT and RTS. Additionally, a negative correlation was determined between CK-MB and RTS and GCS. Similarly, there was a negative correlation between CK-MB/CK and GCS. However, there was no statistically significant relationship between levels of TNF-alpha and the trauma scales (p>0.05).

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Table 3. The correlation coefficient (r) between trauma scales and cardiac markers, admission-hospitalization and discharge period

CKMB/CK

CK-MB

TnT

TNF

GCS

ISS

RTS

Admission period

Hopitalization period

CK

CKMB/CK

CKMB

TnT

TNF

GCS

ISS

RTS

Application

r p r p r p r p r p r p r p r p r p

-0.262 0.008

0.609 0.000 0.303 0.002

0.186 0.064 0.164 0.103 0.402 0.000

-0.011 0.915 -0.082 0.415 -0.153 0.127 -0.121 0.231

-0.127 0.209 -0.197 0.049 -0.249 0.013 -0.189 0.060 0.130 0.196

0.373 0.000 0.263 0.008 0.460 0.000 0.405 0.000 -0.206 0.039 -0.607 0.000

-0.177 0.078 -0.126 0.212 -0.205 0.041 -0.171 0.089 0.131 0.194 0.924 0.000 -0.548 0.000

0.300 0.002 -0.096 0.340 0.189 0.060 0.209 0.037 -0.036 0.724 -0.053 0.598 0.387 0.000 -0.078 0.439

0.379 0.000 -0.129 0.200 0.247 0.013 0.099 0.327 -0.133 0.187 -0.279 0.005 0.339 0.001 -0.291 0.003 0.280 0.005

CK: Creatine inase; CK-MB: Creatine kinase-MB fraction; RTS: Revised Trauma Score; ISS: Injury Severity Score; GCS: Glasgow Coma Scale; TnT: Troponin T.

Evaluating patients according to vital signs during presentation, high fever was present in 1 patient, tachycardia in 75 patients and shock in 10 patients, while 5 patients needed mechanical ventilation. Six of the 10 patients in shock and 4 of 5 mechanically ventilated patients died. It was determined that the CK-MB levels of patients in shock were as follows: Of these, TnT level was high in 1 and abnormal ECHO findings were determined in 2 patients, while other cardiac indicators were normal. CK, CK-MB/CK, CK-MB, TNF-alpha and TnT levels were outside normal range in 93, 90, 70, 40, and 11 cases, respectively (Table 3).

The relationship between vital signs, trauma scores and cardiac injury markers with respect to the prognosis is shown in Table 4. Of 85 patients who underwent a medical intervention at another center, prior to admitting to our department, 19 (22.4%) died; however, none of the patients who transferred directly to our department without any intervention died (p=0.04). Of 24 patients resuscitated at the trauma site, 9 (37.5%) died, while only 10 of 76 patients (13.2%) who had not been resuscitated at the trauma site died (p=0.008). Trauma scores (GCS, ISS, RTS) were found to be significantly different between these two groups. Five (22.7%) of 22 female patients died, while 14 (17.9%) of 78 male patients died (p=0.614).

The mean age of exitus cases was 35.9Âą18.1 years, while the mean age of surviving patients was 32.6Âą14.8 years (p=0.411).

292

DISCUSSION Trauma, one of the most important health problems for our country, commonly affects younger aged individuals and is responsible for considerable physical damage. Approximately 20% of the patients admitted to the ED included patients with chest trauma.[6,7] Traffic collisions are the leading causes of morbidity and mortality worldwide, and a review of the literature revealed that 20% of deaths due to traffic collisions are sourced from trauma-related cardiac injuries.[8,9] In this regard, determining cardiac involvement in traffic collision cases is of high importance to tackle multiple trauma cases and decrease the number of deaths.

Studies aiming to reveal cardiac involvement have been focused mostly on patients with an isolated chest trauma. On the other hand, it has been stated that determining cardiac injuries in multiple trauma cases is a very complex issue.[10] According to Advanced Trauma Life Support (ATLS), a trauma program of the American College of Surgeons, an accurate diagnosis of cardiac contusions can be established by directly observing the myocardium. A previously conducted study revealed myocardial contusion during autopsy in 14% of deaths due to blunt trauma.[11] In order to diagnose cardiac contusion or other cardiac injuries, tests such as ECG, ECHO, blood levels of CK-MB and CK-MB/CK ratio were used in the present study.

Changes in ECG are non-specific and are not reTemmuz - July 2012

Trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients

Table 4. The relationship of factors with prognosis*

Total

Discharge with healing

Death

p

Gender Female/Male (n) Interventions in other institutions No/Yes (n) Trauma interventions at site No/Yes (n)

22/78

15/85

76/24

17/64

15/66

66/15

5/14

0/19

10/9

0.61

Mean±SD Med (min-max)

Mean±SD Med (min-max)

Mean±SD Med (min-max)

36.6±0.6 36.5 (35-39.8) 95.1±19.8 97.0 (44-148) 124.5±23.4 120 (60-190) 77.8±15.5 80 (30-120) 22.1±4.3 20 (5-36) 95.5±7.4 100 (65-100) 14.3±13.3 9.3 (1.1-56.7) 0.053±0.125 0.010 (0.010-0.730) 4.2±10.3 3 (0.3-105) 1908.7±4543.7 778 (66-39950) 0.013±0.010 0.010 (0.001-0.070) 12.1±3.8 15 (3-15) 28.0±15.0 24 (6-66) 7.1±1.2 7.84 (1.46-7.93)

36.6±0.5 36.5 (36-39.8) 95.5±19.1 99 (46-130) 125.5±18.4 120 (75-180) 79.4±13.7 80 (55-120) 21.8±4.4 20 (5-36) 96.5±6.6 100 (65-100) 13.0±12.8 8.1 (1.15-56.7) 0.032±0.074 0.010 (0.010-0.400) 4.6±11.4 3 (0.3-105) 2035.2±4983.1 760 (66-39950) 0.011±0.007 0.010 (0.001-0.040) 12.9±3.1 15 (5-145) 24.9±13.5 22 (6-66) 7.3±0.8 7.84 (4.15-7.84)

36.6±0.7 36.5 (35-38) 93.8±23.4 96 (44-148) 120.0±39.3 110 (60-90) 70.6±20.5 70 (30-110) 23.5±3.3 24 (18-28) 90.9±9.1 92 (70-100) 19.9±14.2 17.9 (2.5-54.3) 0.143±0.226 0.010 (0.010-0.730) 2.8±1.1 2.6 (1.5-5.2) 1369.1±1675.3 836 (79-7547) 0.021±0.014 0.018 (0.005-0.070) 8.8±4.6 7 (3-15) 41.4±14.2 43 (14-66) 6.1±1.7 5.96 (1.46-7.93)

Temperature (C°)

Pulse (minute)

Systolic blood pressure (mmHg)

Diastolic blood pressure (mmHg)

Respiration (minute)

Pulse oximeter

CK-MB (ng/ml)

TnT (ng/ml)

TNF-alpha (pg/ml)

CK (U/L)

CK-MB/CK

GCS

ISS

RTS

0.04 0.008

0.828 0.532 0.209 0.092 0.079 0.003 0.030 0.001 0.004 0.785 0.001 0.0001 0.0001 0.002

*Intervention during another hospitalization-intervention at trauma site; CK: Creatine inase; CK-MB: Creatine kinase-MB fraction; RTS: Revised Trauma Score; ISS: Injury Severity Score; GCS: Glasgow Coma Scale; TnT: Troponin T.

garded as a strong indicator for myocardial contusion in trauma cases; however, it might be indicative of cardiac involvement and of certain complications.[12,13] A meta-analysis by Maenza et al.[14] showed a concordance between important cardiac complications and abnormal ECG findings. It has been reported that every kind of arrhythmia can be diagnosed, while sinus tachycardia, ST-T wave change, ventricular fibrillation, premature atrial and ventricular discharges, atrial fibrillation, and AV blocks have a higher frequency of occurrence and of being diagnosed.[12,14,15] In our study, abnormal ECG finding was determined in 63 of 100 patients. Of these, sinus tachycardia was detected in 36%, right branch block in 13%, ST-T wave changes in 10%, and sinus bradycardia in 4%. Since ECG changes might be secondary to multiple traumas, the coherency of ECG findings and Cilt - Vol. 18 Sayı - No. 4

cardiac enzymes and ECHO was taken into account for the differential diagnosis of cardiac injuries. ST-T wave changes as an index of cardiac injury was determined in 10 patients. Of these, abnormal ECHO findings (ventricular function disorder and pericardial effusion) were detected in four patients, abnormal CK-MB levels in seven, and abnormal TnT and TNFalpha in four patients. Furthermore, CK-MB/CK was abnormal in all patients with abnormal ST-T changes.

Abnormal ECHO was found in 12 of 36 patients with sinus tachycardia. It was noted that three patients with abnormal ECHO findings died following hospitalization.

A previously conducted study monitoring 68 patients by ECHO, ECG and CK-MB revealed that 49 patients had abnormal findings of any of ECHO, ECG or CK-MB tests.[15] 293

Ulus Travma Acil Cerrahi Derg

On the other hand, a statistically significant relationship between ECG changes and ECHO findings was reported in a study dealing with a series of 81 patients by Weiss et al.[16] Abnormal ECHO findings (ventricular function disorders and pleural effusion) were detected in eight of 15 exitus cases.

In the literature, ECHO, ECG findings and cardiac enzymes have been stated to have a high possibility of being abnormal in patients with cardiac injuries secondary to chest trauma.[17,18] ECHO findings were normal in 65% (n=65) of cases, while abnormal ECHO findings were revealed in 31% (n=31) in the present series. The most common finding was ventricular wall motion abnormality as detected in 20% of cases. In accordance with the literature, abnormal ECG findings were determined in 19 of 31 patients with abnormal ECHO findings. According to ISS, of 31 patients with abnormal ECHO findings, 16 were in the severely damaged group. Thus, ECHO evaluation in the ED of patients with high ISS is of high importance for early diagnosis and treatment.

Since skeletal muscle damage causes an increase in levels of CK-MB, such cases require a differential diagnosis from those cases involving myocardial damage. When evaluating trauma patients to determine the cardiac involvement, it has been stated that CK-MB is increased, and CK-MB/CK rates lower than 2.2% were accepted as abnormal. Furthermore, a correlation between increased CK-MB levels and ECHO, ECG and other cardiac enzymes was reported.

Therefore, increased CK-MB is accepted as indicative of cardiac injuries.[19,20] In our series, CK-MB levels ranged between 1.15289.0 ng/ml, with an average level of 18.61 ng/ml.

CK-MB/CK ratio varied between 0 and 0.7. The CK, CK-MB/CK and CK-MB values were found outside normal range in 93, 90 and 70 patients, respectively.

A statistically significant relationship was determined between CK-MB and ISS, TnT, CK, and CK-MB/CK values (p=0.00). A negative correlation was determined between CK-MB and RTS and GCS. In other words, high CK-MB levels were detected in patients with low RTS and GCS. There was no significant relationship between levels of CK-MB and TNF (p=0.18).

Additionally, there was a statistically significant relationship between CK-MB/CK and CK-MB, and CK and CK-MB, and ISS as well (p=0.00). Furthermore, in parallel to the delay in presentation to the hospital, CK-MB and CK-MB/CK values were increased with increasing trauma severity and hospitalization duration.

In light of the above-mentioned data, it is important that patients with high severity points on trauma scales be conveyed to an appropriate health center with full 294

facilities providing quick treatment, which might help to decrease the levels of cardiac injury markers.

TnT, a regulatory protein for myocardial contraction, which is released due to myocyte damage, is not released from skeletal muscle. In the literature, TnT is reported to have a higher sensitivity and specificity compared to other cardiac injury markers, and is stated to be more valuable than CK-MB for the purpose of diagnosis.[20,21] Abnormal TnT values (over 0.1 ng/ml) were detected in 11 patients in our series. Of these, only three patients had a history of cardiac disease. Comparison of TnT with other diagnostic markers revealed that there was a statistically significant relation between CK-MB, ISS and TnT (p=0.00). Furthermore, increase in TnT and CK-MB levels showed a concordance with increased trauma severity scale. Abnormal ECHO findings were determined in four and abnormal ECG was determined in nine of 11 patients with abnormal TnT levels. Use of TnT levels, in addition to the examination of CK-MB, ECHO, ECG, and ISS, was found to be highly valuable in the diagnosis of cardiac injury.

It has been stated that serum TNF levels are increased in circumstances such as blunt trauma, myocardial infarction, cardiopulmonary bypass surgery, congestive cardiac failure, and myocarditis.[22,23] TNFalpha was used as a supportive diagnostic tool to determine cardiac involvement. It was determined that TNF-alpha levels ranged between 0.3-105 pg/ml, with an average level of 4.2 pg/ml. However, it was not statistically significant (p>0.05) when evaluating the coherence of cardiac injury indicators. Of 40 patients with high TNF-alpha levels, only one had a history of cardiac disease (TNF 5.1 pg/ml). Of these, abnormal ECG was determined in 10 cases and abnormal ECHO in five cases. In the literature, it was stated that TNFalpha levels increase in the late period of cardiac injuries. Based on this statement, since our cases were evaluated in the acute period, no increase in TNFalpha levels was determined. Although the diagnostic value of TNF-alpha alone is low, it is valuable as a support for other tests.

Trauma-related researches generally focus on developing and implementing an efficient trauma scoring system through comparing the findings of patients with multiple traumas, which would be useful for patient care. A statistically significant relationship was reported between cardiac contusion and high ISS values (p<0.00).

There was a statistically significant difference in levels of CK-MB and CK between the slight and severe injury groups (p=0.00); however, no significant difference was detected in our series regarding the remaining cardiac injury markers (p>0.05). Abnormal Temmuz - July 2012

Trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients

ECHO was determined in 22 patients while ECG was abnormal in 26 patients in the severely damaged group according to ISS. Increase in the CK-MB level due to multiple traumas, which is specific for cardiac injury, shows the importance of ISS in cardiac injury secondary to multiple traumas. In this regard, the specificity of CK-MB and CK levels to determine cardiac injury severity is higher with ISS than with other trauma scales.

In conclusion, cardiac injury due to multiple trauma, those including chest trauma in particular, is responsible for high morbidity and mortality. ECG remains a sensitive test for diagnosis of blunt cardiac injuries. Especially in the cases with abnormal ECG, evaluating the troponin levels is of high importance for determining increased risk of death. Of cases with blunt chest trauma, those with cardiac disease history, hemodynamic instability, abnormal ECG, high troponin and CK-MB levels, and high trauma severity scores should be followed using intensive cardiac monitoring. Furthermore, those chest trauma patients admitted with chest pain, rib and sternum fractures, and lung damage should also be followed for at least the first 24 hours for blunt cardiac injury. Those patients should additionally be evaluated by ECHO to diagnose and treat possible pericardial tamponade in the early period.

REFERENCES 1. Battistella FD, Benfield JR. Blunt and penetrating injuries of the chest wall, pleura and lungs. In: Shield TW, editor.

General thoracic surgery. 5th ed. Philadelphia: Williams and Wilkins; 2000. p. 815-63.

2. Şentürk E, Doğan Y, Yoldaş E. Thoracic trauma: analysis of 1142 cases. Turkish Thoracic Journal 2010;11:47-54.

3. Saadeddin SM, Habbab MA, Sobki SH, Ferns GA. Minor myocardial injury after elective uncomplicated successful PTCA with or without stenting: detection by cardiac troponins. Catheter Cardiovasc Interv 2001;53:188-92.

4. Bertinchant JP, Polge A, Mohty D, Nguyen-Ngoc-Lam R, Estorc J, Cohendy R, et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma 2000;48:924-31.

5. Maass DL, Hybki DP, White J, Horton JW. The time course of cardiac NF-kappaB activation and TNF-alpha secretion by cardiac myocytes after burn injury: contribution to burnrelated cardiac contractile dysfunction. Shock 2002;17:2939.

6. Buchman TG, Hall BL, Bowling WM, Kelen GD. Thoracic trauma. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors.

Emergency medicine: a comprehensive study guide. New York: McGraw-Hill; 2004. p. 1595-613.

7. Balcı AE, Eren N, Eren Ş, Ülkü R, Onat S, Cebeci E. Fac-

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tors influencing mortality in trauma thoracotomy. Journal of Turkish Chest Cardiac Vein Surgery 2001;9:215-20.

8. Burgut HR, Bener A, Sidahmed H, Albuz R, Sanya R, Khan WA. Risk factors contributing to road traffic crashes in a fast-developing country: the neglected health problem. Ulus Travma Acil Cerrahi Derg 2010;16:497-502.

9. Kapadıa SR, Topol EJ. Cardiac trauma. In: Topol EJ, editor.

Textbook of cardiovascular medicine. Ohio: Cordisgroup; 2005. p. 901-15.

10. Gumanenko EK, Kochergaev OV, Gavrilin SV, Nemchenko NS, Boiarintsev VV. Diagnosis of heart contusions in patients with multiple trauma of the chest. [Article in Russian] Vestn Khir Im I I Grek 2000;159:36-40.

11. Bansal MK, Maraj S, Chewaproug D, Amanullah A. Myocardial contusion injury: redefining the diagnostic algorithm.

Emerg Med J 2005;22:465-9.

12. Potkin RT, Werner JA, Trobaugh GB, Chestnut CH 3rd, Carrico CJ, Hallstrom A, et al. Evaluation of noninvasive tests of cardiac damage in suspected cardiac contusion. Circulation 1982;66:627-31.

13. Fang BR, Li CT. Acute myocardial infarction following blunt chest trauma. Eur Heart J 1994;15:705-7.

14. Maenza RL, Seaberg D, D’Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med 1996;14:237-41.

15. Yuan Y, Ren J, Zhang W, Chen J, Li J. The effect of different temporary abdominal closure materials on the growth of granulation tissue after the open abdomen. J Trauma 2011;71:961-5.

16. Weiss RL, Brier JA, O’Connor W, Ross S, Brathwaite CM. The usefulness of transesophageal echocardiography in diagnosing cardiac contusions. Chest 1996;109:73-7.

17. Wiener Y, Achildiev B, Karni T, Halevi A. Echocardiogram in sternal fracture. Am J Emerg Med 2001;19:403-5.

18. Markiewicz W, Best LA, Burstein S, Peleg H. Echocardiographic evaluation after blunt trauma of the chest. Int J Cardiol 1985;8:269-74.

19. Pasquale MD, Nagy K, Clarke J. Practice management guidelines for screening of blunt cardiac injury. In: Practice management guidelines for trauma. The EAST Practice Management Guidelines Work Group: Eastern Association For The Surgery of Trauma, 1998. Available from URL: http://www. east.org/tpg/chap2.pdf [Accessed July, 2012].

20. Fulda GJ, Giberson F, Hailstone D, Law A, Stillabower M. An evaluation of serum troponin T and signal-averaged electrocardiography in predicting electrocardiographic abnormalities after blunt chest trauma. J Trauma 1997;43:304-12.

21. Riou B. Troponin: important in severe trauma and a first step in the biological marker revolution. Anesthesiology 2004;101:1259-60.

22. Latini R, Bianchi M, Correale E, Dinarello CA, Fantuzzi G, Fresco C, et al. Cytokines in acute myocardial infarction: selective increase in circulating tumor necrosis factor, its soluble receptor, and interleukin-1 receptor antagonist. J Cardiovasc Pharmacol 1994;23:1-6.

23. Pomerantz BJ, Reznikov LL, Harken AH, Dinarello CA. Inhibition of caspase 1 reduces human myocardial ischemic dysfunction via inhibition of IL-18 and IL-1beta. Proc Natl Acad Sci U S A 2001;98:2871-6.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):296-300

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.26928

Burn unit: colonization of burn wounds and local environment Yanık ünitesi: Yanık yarası ve yerel çevresinde kolonizasyon Touria ESSAYAGH,1 Alban ZOHOUN,2 Khalid TOURABI,3 Mohamed Amine ENNOUHI,3 Abdellatif BOUMAAROUF,3 Hsain IHRAI,3 Sakina ELHAMZAOUI2

BACKGROUND

AMAÇ

We present the results of a comparative prospective study of the resistance profile of strains isolated from pathological material of patients hospitalized in the burn unit of the military hospital in Rabat and from their environment over a period of one and a half years (July 2009-February 2011).

Rabat’daki askeri hastanenin yanık ünitesine yatırılan hastalardan ve bunların çevrelerinden 1,5 yıllık bir süre içinde (Temmuz 2009-Şubat 2011) elde edilen patolojik materyalden izole edilen suşların direnç profiline ait karşılaştırmalı bir prospektif çalışmanın sonuçları sunuldu.

METHODS

GEREÇ VE YÖNTEM

The study concerned 125 pathological products from patients (40 men, 20 women; mean age 38±14.8 years; range 2 to 80 years) hospitalized with burns. This allowed the isolation of 86 non-redundant bacterial strains during the first period and 50 during the second.

Bu çalışmada, yanıkları nedeniyle hastaneye yatırılan hastalara (40 erkek, 20 kadın; ort. yaş 38±14.8; dağılım, 2-80 yaş) ait 125 patolojik ürünle çalışıldı. Birinci periyot süresinde 86, ikinci periyot süresinde de 50 artıksız bakteriyel suş izole edildi.

RESULTS

BULGULAR

The dominant species were Acinetobacter baumannii (15.6%), followed by Pseudomonas aeruginosa (13.8%) and Staphylococcus aureus (11%). During the second period, we noted the abundance of A. baumannii (15.5%), followed by P. aeruginosa (11.3%) and Klebsiella pneumoniae (8.5%). Of the 104 environmental samples of burn patients, 139 microorganisms were isolated. Coagulase-negative staphylococcus was the most abundant strain in the two study periods (69.2% and 64.6%).

Baskın suşlar sırasıyla, Acinetobacter baumannii (%15,6), Pseudomonas aeruginosa (%13,8) ve Staphylococcus aureus (%11) oldu. İkinci periyot süresinde A. baumannii (%15,5), P. aeruginosa (%11,3) ve Klebsiella pneumoniae (% 8,5) suşlarının çok olduğunu saptandı. Yanıklı hastalardan elde edilen 104 çevresel örnekten 139 mikroorganizma izole edildi. Koagülaz-negatif stafilokok, iki çalışma periyodunda da en fazla görülen suş oldu (%69,2 ve %64,6).

CONCLUSION

SONUÇ

All species showed an almost identical sensitivity to the various antibiotics tested.

Bütün suşlar, test edilen değişik antibiyotiklere karşı hemen hemen özdeş bir duyarlılık göstermiştir.

Key Words: Antibiotic resistance; bacterial ecology; burn patient; burn unit.

Anahtar Sözcükler: Antibiyotik direnci; bakteriyel ekoloji; yanık hastası; yanık ünitesi.

1 Medicine College of Rabat, University Mohamed V Souissi, Rabat; Department of Microbiology, Military Teaching Mohamed V Hospital, Rabat; 3Burn Unit, Military Teaching Mohamed V Hospital, Rabat, Morocco.

2

1 Mohamed V Souissi Üniversitesi, Rabat Tıp Fakültesi, Rabat; Mohamed V Askeri Eğitim Hastanesi, Mikrobiyoloji Bölümü, Rabat; 3 Mohamed V Askeri Eğitim Hastanesi, Yanık Birimi, Rabat, Fas.

2

Correspondence (İletişim): Touria Essayagh, M.D. Medicine College of Rabat, University Mohamed V Souissi, Rabat, Morocco.

Tel: +00212 - 669679966 e-mail (e-posta): essayagh.toula@gmail.com

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Burn unit: colonization of burn wounds and local environment

Intensive care units of hospitals include seriously ill patients who are extremely vulnerable to infections.

Those units and their patients provide a niche for opportunistic organisms that are generally harmless to healthy people but are often very resistant to antibiotics and can cause epidemic spread among patients.

[1] Indeed, infections by those microorganisms are difficult to treat and may lead to increased morbidity and mortality in weakened burn patients,[2-5] thereby increasing associated costs of care. The Burns Unit (BU) of the Military Hospital in Rabat is one of those intensive care units; it contains 14 beds with three in reanimation, two baths, two operating rooms, and toilets.

Our study aims were to identify the bacteria responsible for infections in immunodepressed patients and to determine their antibiotic sensitivity profile in order to reduce the risks related to infections and to better inform probabilistic antibiotic therapy.

MATERIALS AND METHODS We divided our study into two periods: the first period of 10 months and the second for eight months, separated by a maintenance phase in the BU, primarily involving painting the walls. During this renovation period, the BU remained operational.

Patients Sixty patients admitted to the BU in the Military Hospital in Rabat, Morocco during the period from 28 July 2009 till 1 February 2011 were included in this study. There were 20 women and 40 men. Their ages ranged from 2-80 years, with a mean of 38±14.8 years.

The causes of burn were exposure to flame (n=53), electricity (n=3) and nitric acid (n=1), while the rest represented toxic epidermal necrolysis syndrome.

These three patients did not present any mucosal complication like gastrointestinal bleeding or perforation.

The total body surface area (TBSA) burned was divided as ≤15% or >15%, with an average of 30±12.73%.

Biological materials The microbial colonization of all wounds was studied from admission till the last surgical procedure. Upon admission, bacteriological samples were taken. The sampling procedure was carried out after cleaning each wound. Later, swabs were taken on occasions of surgical debridement or surgical excision and grafting. In each sampling procedure, the bandages were removed, the remnants of any topical antimicrobial agents were scraped away, and the wounds were swabbed before washing and applying the new topical antimicrobial agent. Sampling of environmental swabs from patients was done a few days after admission.

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Microbiology Isolation of microorganisms was primarily on blood agar plates, and identification was made based on morphological and biochemical characteristics. Antibiotic susceptibility was performed using the method of agar diffusion on Mueller-Hinton with use of antibiotic discs. The bacteria were classified as categorysensitive (S) or resistant (R) following the recommendations of the French Society for Microbiology.

RESULTS The bacterial profile of microbial samples taken from the wounds of burn patients during the two study periods is shown in Table 1.

The first period of this study concerned 76 bacteriological samples as opposed to 49 during the second period: 35.2% corresponded to superficial pus, 35.2% to blood cultures, 10.4% to cytobacteriological urine studies, 12% to catheters, and 5.6% to “other”. During the first part of the study, 86 bacteria were identified, predominantly as Acinetobacter baumannii (15.6%), Pseudomonas aeruginosa (13.8%) and StaphylococTable 1. Organisms isolated from wounds of burn patients in the two periods (2009-2011)

First period

Second period

n (%)

n (%)

Enterobacteriaceae

Citrobacter koseri 1 (0.9%) – Comamonas testosterone 1 (0.9%) 1 (1.4%) Escherichia coli 2 (1.8%) 1 (1.4%) Enterobacter cloacae 6 (5.5%) 5 (7%) Serratia marcescens 2 (1.8%) 1 (1.4%) Klebsiella pneumoniae 7 (6.4%) 6 (8.5%) Morganella morganii 1 (0.9%) 0 (0%) Pantoea spp 1 (0.9%) 0 (0%) Proteus mirabilis 6 (5.5%) 2 (2.8%) Proteus vulgaris 3 (2.8%) 2 (2.8%) Providencia stuartii 1 (0.9%) 0 (0%) Nonfermenting Gram-negative bacilli

Stenotrophomonas maltophilia 1 (0.9%) 0 (0%) Ralstonia pickettii 2 (1.8%) 0 (0%) Pseudomonas aeruginosa 15 (13.8%) 8 (11.3%) Acinetobacter baumannii 17 (15.6%) 11 (15.5%) Cocci

Enterococcus faecalis 3 (2.8%) 2 (2.8%) Staphylococcus aureus 12 (11%) 5 (7%) Coagulase-negative staphylococcus 2 (1.8%) 5 (7%) Streptococcus spp 3 (2.8%) 1 (1.4%) Other

Candida albicans 2 (1.8%) 1 (1.4%) Candida non albicans 2 (1.8%) 1 (1.4%) Sterile 19 (17.4%) 19 (26.8%) Total 109 (100%) 71 (100%)

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Table 2. Organisms isolated from the environment of burn patients during the two periods (20092011)

First period

Second period

n (%)

n (%)

Enterobacteriaceae Escherichia coli 1 (1.1%) Nonfermenting Gram-negative bacilli

Pseudomonas aeruginosa 1 (1.1%) Acinetobacter baumannii ND Pasteurella haemolytica 1 (1.1%) Cocci

Staphylococcus aureus 13 (14.3%) Coagulase-negative staphylococcus 63 (69.2%) Fungi Aspergillus niger 1 (1.1%) Aspergillus spp 7 (7.7%) Mucor spp 4 (4.4%) Total 91 (100%)

0 (0.0%) 3 (6.3%) 1 (2.1%) 0 (0.0%) 8 (16.7%) 31 (64.6%) 0 (0.0%) 5 (10.4%) 0 (0.0%) 48 (100%)

cus aureus (11%), whereas during the second period, 50 bacteria were isolated, with an abundance of A. baumannii (15.5%), followed by P. aeruginosa (11.3%) and Klebsiella pneumoniae (8.5%).

The profile of microorganisms in the environment of burn patients during the study periods is shown in Table 2.

The first period of the study concerned 69 samples versus 35 in the second. 31.4% corresponded to surface samples, 25.7% to air samples, 20% to lower than the table surface, 11% to the bedside, and 5.5% each to the sheets and bathtubs.

Ninety-one microorganisms were isolated during the first period of the study, with 12 corresponding to fungi, in contrast to 48 microorganisms in the second period, with 5 corresponding to fungi. Coagulase-negative staphylococcus (CNS) and S. aureus strains were most abundant during the study period.

The study of the sensitivity profile to the antibiotics tested concerned the three most abundant species.

Staphylococci: We followed the resistance of S. aureus and CNS to fusidic acid (FA), erythromycin (E), penicillin (oxacillin [OXA]), aminoglycosides (tobramycin [TOB] and gentamicin [GN]), and glycopeptides (vancomycin [VA] and teicoplanin [TEC]).

The results are summarized in Table 3. The S. aureus isolated during the study showed that resistance was around 40% for FA, E and OXA. Their sensitivity to glycopeptides is absolute. 23.5% of S. aureus isolated were methicillin-resistant S. aureus (MRSA). CNS were relatively sensitive to the different antibiotics tested.

Nonfermenting Gram-negative bacilli: The percentage of resistance of A. baumannii and P. aeruginosa isolated during the different periods of the study is shown in Table 4. P. aeruginosa showed sensitivity to the different antibiotics tested.

K. pneumoniae showed sensitivity to amikacin (AN), colistin (CS), fosfomycin (FOS), carbapenems (imipenem [IMP]), and ticarcillin (TIC). However, sensitivity to netilmicin (NET), sulfamethoxazole trimethoprim (SXT), ciprofloxacin (CIP), and amoxicillin acid (AMC) was relatively low. 8.2% of Enterobacteriaceae identified corresponded to Enterobacteriaceae with extended-spectrum beta lactamase (ESBL).

Staphylococci: We followed the resistance of S. aureus and CNS to the same antibiotics for Staphylococci isolated from patientsâ&#x20AC;&#x2122; wounds. The results are summarized in Table 5. CNS was sensitive to the different antibiotics tested, while S. aureus showed marked resistance to penicillins, GN, NIV, E, and TEC and sensitivity to VA. 23.8% were MRSA. Nonfermenting Gram-negative bacilli: The three strains of P. aeruginosa isolated during the second period of the study showed 66.7% resistance to TIC and cephalosporin 3 G (ceftazidime [CAZ]) and absolute sensitivity to IMP and amikacin (AK).

DISCUSSION Prior and present knowledge of the bacterial profile of the BU and of the profile of bacterial sensitivity

Table 3. Antibiotic resistance profiles for Staphylococcus spp from wounds of burn patients in the two periods (2009-2011)

First period

Staphylococcus aureus (n=12, CNS n=2)

Second period Staphylococcus aureus

(n=5, CNS n=5)

AF n (%)

E n (%)

GN n (%)

KA n (%)

OXA n (%)

TEC n (%)

TOB n (%)

VA n (%)

5 (41.7%) 5 (41.7%) 4 (33.3%) 1 (8.3%) 4 (33.3%) 0 (0%) 5 (41.7%) 0 (0%) 2 (100%) 1 (50%) 1 (50%) 1 (50%) 1 (50%) 0 (0%) 2 (100%) 0 (0%) 2 (40%) 0 (0%)

2 (40%) 0 (0%)

3 (60%) 1 (20%)

2 (40%) 1 (20%)

2 (40%) 1 (20%)

ND 0 (0%)

3 (60%) 1 (20%)

0 (0%) 0 (0%)

AF: Fusidic acid; E: Erythromycin; GN: Gentamicin; KA: Kanamycin; TEC: Teicoplanin; OXA: Oxacillin 5 Âľg; TOB: Tobramycin; VA: Vancomycin; ND: Not determined.

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Burn unit: colonization of burn wounds and local environment

Table 4. Antibiotic resistance profiles for nonfermenting Gram-negative bacilli from wounds of burn patients in the two periods (2009-2011)

Amikacin

Ceftazidime

Imipenem

Ticarcillin

n (%)

n (%)

n (%)

n (%)

P. aeruginosa (n=15) A. baumannii (n=17)

4 (12.5%) 11 (34.4%)

3 (20%) 14 (43.8%)

4 (26.7%) 1 (3.1%)

6 (40%) 14 (43.8%)

P. aeruginosa (n=8) A. baumannii (n=11)

2 (6.9%) 6 (20.7%)

3 (10.3%) 11 (37.9%)

3 (10.3%) 8 (27.6%)

7 (24.1%) 8 (27.6%)

First period

Second period

Table 5. Antibiotic resistance profiles for Staphylococcus spp from the environment of burn patients in the two periods

(2009-2011)

First period

CNS=63 S. aureus (n=13)

Second period CNS=31

S. aureus (n=8)

AF n (%)

E n (%)

GN n (%)

KA n (%)

OXA n (%)

TEC n (%)

TOB n (%)

VA n (%)

12 (19.0%) 6 (9.5%) 18 (28.6%) 7 (11.1%) 8 (12.7%) 7 (11.1%) 2 (3.2%) 0 (0%) 5 (38.5%) 5 (38.5%) 4 (30.8%) 4 (30.8%) 3 (23.1%) 4 (30.8%) 2 (15.4%) 0 (0%) 2 (6.5%) 6 (19.4%) 7 (22.6%) 1 (3.2%) 3 (9.7%) 4 (12.9%) 1 (0%) 5 (62.5%) 5 (62.5%) 4 (50.0%) 4 (50.0%) 3 (37.5%) 4 (50.0%) 2 (0%)

0 (0%) 0 (0%)

AF: Fusidic acid; E: Erythromycin; GN: Gentamicin; KA: Kanamycin; TEC: Teicoplanin; OXA: Oxacillin 5 µg; TOB: Tobramycin; VA: Vancomycin.

to antibiotics by isolates is necessary for the successful treatment of severe infections. We undertook this study to identify the bacteria responsible for infections in immunodepressed patients and to determine their antibiotic sensitivity profile. During the course of the study, we analyzed 129 bacteriological samples from wounds of patients in the BU, and 136 non-redundant bacterial strains were identified. Thirty-eight samples were sterile. One hundred and four environmental samples were obtained, and 122 bacterial strains were identified.

P. aeruginosa was the second most abundant species in both study periods, and its sensitivity to the antibiotics tested was shown. This was corroborated by other authors like Revathi, Panit, Lari, and Kaushik.

[6-9]

This high rate of P. aeruginosa could be explained by the exposure of patients to balneotherapy.[10,11] Tredget[11] mentions in his study that the bacilli pyocyaneus easily survive in the aquatic environment due to their low nutrient requirements exogenously; hence, the advantage of dressings in bed. Cremer[12] found an abundance of P. aeruginosa in the early practice of hydrotherapy.

A. baumannii was the most dominant strain in our study, and it showed resistance to the various antibiotics tested. Those strains can be found in various sites in the patient’s environment, including bed curtains, furniture and hospital equipment.[13] This bacteria can be spread through the air over short distances in water droplets and in the scales of the skin of patients Cilt - Vol. 18 Sayı - No. 4

who are colonized,[14] but the most common mode of transmission is from the hands of hospital staff. Patients who are colonized or infected by A. baumannii can carry this strain at different body sites for periods of days to weeks.[15] A. baumannii can survive in dry conditions.[16] The various strains of Staphylococcus spp isolated have shown almost the same sensitivity phenotype, with the presence of 23% of MRSA. The majority of our identified strains showed almost the same pattern of antibiotic resistance, allowing us to deduce that there are clones that are circulating in our BU that pass from one room to another via the medical staff and paramedics, and via hospital patients who have been transferred to other rooms. These factors may also explain the presence of almost the same rate of MRSA isolated from wounds of patients as from their environment (±23%). Currently, the emergence of strains of S. aureus with reduced susceptibility to vancomycin (VA) is a major problem, especially after the first Japanese report described the isolation of a strain of S. aureus resistant to VA. In our study, among the 38 strains of S. aureus studied, no strain was resistant to glycopeptides accounted for by VA.[17,18] The same result was not found in a Tunisian University Hospital.

[19] The renovation that was undertaken in the BU involved primarily painting the walls, and resulted in the elimination of Aspergillus niger and Mucor sp.

This should be complemented by other more stringent measures and tips to ensure a reduction of bacterial infections of patients’ wounds.

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Faced with the risk of multi-resistant bacteria broadcasts within the unit or the hospital, the establishment of a program to combat the spread of these bacteria and compliance with standards of hospital hygiene are paramount.

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13. van den Broek PJ, Arends J, Bernards AT, De Brauwer E, Mascini EM, van der Reijden TJ, et al. Epidemiology of multiple Acinetobacter outbreaks in The Netherlands during the period 1999-2001. Clin Microbiol Infect 2006;12:837-43.

14. Bernards AT, Frénay HM, Lim BT, Hendriks WD, Dijkshoorn L, van Boven CP. Methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii: an unexpected difference in epidemiologic behavior. Am J Infect Control 1998;26:544-51.

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16. Jawad A, Seifert H, Snelling AM, Heritage J, Hawkey PM. Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreak and sporadic isolates. J Clin Microbiol 1998;36:1938-41.

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19. Garnier F, Mariani-Kurkdjian P, Nordmann P, Ferroni A, VuThien H, Philippe JC, et al. Sensibilité aux antibiotiques des souches de staphylocoques et d’entérocoques isolées en pédiatrie. Médecine et Maladies Infectieuses 2002;32:432-8.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):301-305

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.69158

Cardiac monitoring in patients with electrocution injury Elektrik çarpması yaralanması olan hastalarda kardiyak monitörizasyon Meltem AKKAŞ,1 Hilal HOCAGİL,1 Didem AY,2 Bülent ERBİL,1 Mehmet Mahir KUNT,1 Mehmet Mahir ÖZMEN1 BACKGROUND

AMAÇ

The necessity of admitting patients exposed to electrocution injuries for monitoring and observation in the emergency department (ED) remains controversial.

Elektrik çarpması kazasıyla yaralanan hastaların, monitörizasyon ve izlem için acil servise kabulü tartışmalıdır.

METHODS

Son 20 yıl içinde, elektrik kazası nedeni ile erişkin acil servise başvuran 102 hastanın (86 erkek, 16 kadın; ort. yaş 29.5; dağılım 18-68 yaş) kayıtları değerlendirildi.

We evaluated the medical records of 102 patients (86 male, 16 female; median age 29.5; range 18 to 68 years) admitted to the adult ED with electrocution injuries over the past 20 years.

RESULTS

Only 9 deaths were reported: 3 as a result of contact with low-voltage electricity and 6 after contact with high-voltage electricity. With the exception of a case of sepsis, all deaths were related to early rhythm abnormalities immediately following the incident. The ECG findings of surviving patients in the study group were as follows: 70 normal, 8 sinus tachycardia, 3 sinus bradycardia, 4 ST-T wave changes, and 1 ventricular extrasystole. ECG recordings of 7 patients could not be found. 72 cases had been followed up with repeat ECG recordings. There were no observed ECG changes requiring any medical or electrical therapies in the surviving patients.

CONCLUSION

Cardiac rhythm abnormalities related to electrocution injuries are usually observed at the time of the incident. If the patient’s overall clinical condition is good and they have a normal ECG at the time of admission to the ED, the probability of observing any delayed serious dysrhythmia is unlikely.

GEREÇ VE YÖNTEM

BULGULAR

Hastaların üçünde düşük, altısında yüksek voltaj teması nedeniyle dokuz olguda ölüm görüldü. Bir sepsis olgusu dışında, diğer olguların hepsinde ölüm, olayın hemen sonrasında gelişen erken ritim bozukluklarına bağlı idi. Yaşayan hastalarda izlenen EKG bulguları; 70’inde normal, 8’inde sinüs taşikardisi, üçünde sinüs bradikardisi, dördünde ST-T dalga değişiklikleri, birinde ventriküler ekstrasistol olup, yedi olguda EKG kayıtlarına ulaşılamadı. Olguların 72’si tekrarlayan EKG çekimleri ile izlendi. Yaşayan hastaların hiçbirinde medikal ya da elektriksel tedavi gerektirecek herhangi bir EKG değişikliği izlenmedi.

SONUÇ

Elektrik yaralanmalarına bağlı kardiyak ritim anomalileri genellikle olay anında görülür. Eğer hasta klinik olarak iyi, acil servise kabulünde normal EKG’ye sahip ise, gecikmiş ciddi bir ritim bozukluğu görülme olasılığı pek mümkün değildir.

Key Words: Electrical injury; cardiac monitoring.

Anahtar Sözcükler: Elektrik yaralanması; kardiyak monitörizasyon.

Almost all electrical injuries are admitted to the emergency department (ED). Although they are not seen commonly, these incidents are associated with a high degree of morbidity and mortality since the injury can affect various systems of the body.[1] The magni-

tude of voltage to which the victim has been exposed, the resistance of the body, exposure to either direct or alternating current, the duration of exposure, and the pathway of the current inside the body all affect the potential mortality and morbidity.

1 Department of Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara; 2Department of Emergency Medicine, Yeditepe University Faculty of Medicine, Istanbul, Turkey.

Hacettepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara; 2 Yeditepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İstanbul.

1

Correspondence (İletişim): Meltem Akkaş, M.D. Hacettepe Üniversitesi Tıf Fakültesi, Büyük Acil Polikliniği, Sıhhıye 06100 Ankara, Turkey.

Tel: +90 - 312 - 305 25 05 e-mail (e-posta): meltemakkas@hotmail.com

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High-voltage injuries occur at 1,000 volts or greater. These are most commonly work- related injuries and typically observed in males. Low-voltage injuries (<1000 volts) are usually observed in females and children as domestic injuries. Though high-voltage electrical injuries are more dangerous, low-voltage electrical injuries are observed more frequently.[2] Electrocution accidents can lead to injuries in 3-54% of exposed patients, and the severity can range from minimal to life-threatening injuries.[2-7] The cardiovascular, musculoskeletal and nervous systems, kidneys, and skin are most affected, with the primary cause of death being cardiac arrest. It is also known that the serious cardiac effects usually occur just after the injury. Beyond this period, the ideal length of time for observation and monitoring has been a source of controversy among clinicians.

The present study evaluates the cardiac problems in electrically injured patients via a review of the records of clinical findings, ECG findings, cardiac enzyme levels, and monitoring. In addition to the identified cardiac problems and injuries, we aimed to determine the necessary duration of observation.

MATERIALS AND METHODS We evaluated the records of patients with electrical injury admitted to the adult ED of Hacettepe University Medical Center over the past 20 years after obtaining the approval of the ethical committee. A total of 215 patients were found, with 113 patients excluded due to insufficient hospital records. One hundred and two patients were included in the study. Data regarding age, sex, cause of electrical injury, type of current, incident time, hospital admission time, symptoms during admission, hospital stay, cause of death, rate of ED discharge and admittance to wards, duration of observation for cardiac complications, ECG changes during the observation period, and cardiac enzyme levels were collected. Data recorded for the purpose of this study are presented as frequencies and percentages. All data were evaluated retrospectively using the Statistical Package for the Social Sciences (SPSS) 17.00 (Chicago, IL, USA).

and the remaining 3% (n=3) were admitted after 5 h.

The time periods of admissions were as follows: 58% (n=59) between 08:00-17:00, 36% (n=37) between 17:00-24:00, and 6% (n=6) between 24:00-08:00. Approximately 33% of all admissions (n=34) were between 13:00-15:00.

Thirty-nine percent (n=40) of injuries occurred at work, 37% (n=38) at home, and 24% (n=24) on the street outside home or work.

Sixty-seven percent (n=68) of the injuries resulted from a low-voltage current, while 33% (n=34) resulted from a high-voltage current. Thirty-seven percent of the low-voltage injuries (n=25) were from an electric cable, 21% (n=14) from a power outlet, 22% (n=15) during the repair of an electric-powered household gadget, 10% (n=7) from an electric heater, 3% (n=2) from a light bulb, and 7% (n=5) due to other reasons.

Sixty-eight percent (n=23) of high-voltage injuries resulted from contact with a high-voltage line and the remaining 32% (n=11) from contact with an electrical transformer. The presenting symptoms were as follows: 55% (n=56) burns alone, 16% (n=16) trauma with loss of consciousness, 8% (n=8) cardiac arrest (accompanied by trauma in 5 patients), 6% (n=6) burns and trauma, 5% (n=5) burns and loss of consciousness, and 5% (n=5) pain and numbness at the area of contact; the remaining 5% (n=6) were asymptomatic (Table 1).

Of 21 patients with loss of consciousness, twothirds were exposed to low-voltage electrical current and one-third to high-voltage electrical current. Forty-five low-voltage and 22 high-voltage burns were observed. Eighteen major and 49 minor burns were observed.

The 15 low and 12 high-voltage electrical injuries were accompanied by trauma in a total of 27 cases, of which 19 were minor and 8 were major traumas.

The electrical axis was parallel to the body axis in 28% (n=29), vertical to the body axis in 26% (n=27), and unknown in 45% (n=46) of the patients. The electrical axis was inclusive of vital organs in 36% (n=37) patients and non-inclusive in 19% (n=19). Inclusion was not evident in 45% (n=46).

RESULTS There were 102 patients aged between 18 and 68 years, with a median age of 29.45Âą11.7 years. Eightyfour percent (n=86) of the patients exposed to electricity were male and 16% (n=16) were female. The mean age of males was 29Âą11 years and of women 32Âą12 years.

The survival rate was 91% (n=93). Sixty percent (n=64) were discharged from the ED. The observation times of the discharged patients in the ED were as follows: 3% (n=2) in 0-1 h, 9% (n=6) in 1-2 h, 27% (n=17) in 2-4 h, 55% (n=35) in 4-24 h, and 6% (n=4) in more than 24 h.

Fifty percent (n=51) of the patients were admitted to the ED within the first 30 minutes (min) after the incident, 25% (n=26) between 30-60 min, 11% (n=11) between 1-2 hours (h), 11% (n=11) between 2-4 h,

Hospitalization rates were as follows: 20% (n=19) to the burns unit, 4% (n=4) to intensive care, 3% (n=3) to the orthopedics and trauma unit, and 3% (n=3) to other units.

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Table 1. The distribution of the victims according to symptoms and type of electrical current Presenting symptom

Low-voltage (n)

High-voltage (n)

Total (n)

38 10 5 3 5 4 2 1

18 6 1 3 0 1 3 2

56 16 6 6 5 5 5 3

Burn Loss of consciousness & trauma Asymptomatic Burn & trauma Pain & numbness Loss of consciousness & burn Cardiac arrest & trauma Cardiac arrest

are consistent with the literature, which suggests a large proportion of occupational electrical injuries are seen in young men. This is probably due to the fact that the vast majority of workers in the electrical industry are men.

The initial ECG findings in surviving patients were as follows: 76% (n=70) normal, 9% (n=8) sinus tachycardia, 3% (n=3) sinus bradycardia, 4% (n=4) ST-T wave changes, and 1% (n=1) premature ventricular contractions. ECG records could not be found for 7% (n=7) of the surviving patients.

Although the majority of the injuries in this study occurred as a result of contact with a low-voltage source, most of the deaths occurred as a result of high-voltage injuries. In addition to the voltage of the current, the path of the current through the body, the resistance of the tissue and exposure to either alternative or direct current are important factors affecting morbidity and mortality. Although the records under review revealed that three of the deaths were caused by low-voltage electricity, all these patients’ vital organs had been affected by the electrical current and two cases also had severe trauma.

ECG monitoring was performed in 71% (n=72) of the cases. Patients with sinus tachycardia initially returned to normal sinus rhythm. Excluding the 8 cases of cardiac arrest that developed at the time of the event and one case of sepsis, no ECG changes requiring medical or electrical therapy were observed.

The cardiac enzymes of these patients were tested.

They were high in 4% (n=4); however, these patients were not diagnosed as having acute coronary syndromes (Table 2).

A total of 2 females and 7 males died. The mean age of mortality was 23, and all were occupational accidents; 3 had been exposed to low-voltage electricity and 6 to high-voltage electricity. Five patients also had serious trauma. One died because of delayed sepsis; 7 had asystole and 1 had ventricular fibrillation (VF) at the time of admission to the ED.

Both low- and high-voltage injuries can cause trauma. However, high-voltage current causes large single muscle contractions. Since the victim is thrown by these contractions, secondary traumas are more common in high-voltage current injuries. Therefore, patients subjected to electrical injury should be evaluated carefully and the possibility of multiple trauma should be considered.[10]

DISCUSSION More than 80% of patients injured as a result of electrocution at the workplace are male, as presented in many studies.[8,9] The findings of the present study

In the present study, the mortality rate was 9%, which is similar to previous reports.[11] Aside from one case of sepsis, the other eight deaths occurred due to

Table 2. Cardiac monitoring results in the surviving patients ECG finding Normal Abnormal Sinus tachycardia Sinus bradycardia ST-T changes Premature ventricular contraction No record Total Cilt - Vol. 18 Sayı - No. 4

Initial ECG (n)

Low voltage (n)

High voltage (n)

ECG monitoring (n)

Elevated cardiac enzymes (n)

Treatment (n)

70 16 8 3 4 1 7 93

54 6 3 1 2 – 5 65

16 10 5 2 2 1 2 28

16 10 5 2 2 1 2 28

2 2

– – – – – – – –

2 – 4

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Ulus Travma Acil Cerrahi Derg

cardiac problems that started at the time of electrical injury.

High-voltage injuries generally cause asystole; however, low-voltage injuries more commonly cause VF. Seven asystole cases were observed at the time of admission to the ED. The initial cardiac rhythm may have been different immediately following the accident, and it is possible that the patient may have developed asystole during transportation to the ED. Only one victim who had been injured by low-voltage electricity had VF rhythm on arrival to the ED. More than half of the patients had been kept in the observation unit for 4-24 hours in the Medical Center.

The necessity of observation and ideal monitoring period for patients who have suffered electrocution is under debate. Inclusion criteria as well as the monitoring periods were different in the published studies. The monitoring periods in the studies are usually 6 h,[12] 6-8 h[9] and 24 h.[2,4,13] Some of the studies evaluated patients exposed to high-voltage[4,7,14] or low-voltage [9,12] electricity, while others focused on both low and high voltage.[2] Electrical current disrupts the normal electrophysiological system by causing thermal and ischemic myocardial injury. Often, sinus tachycardia and premature ventricular contractions are observed, but serious rhythm disturbances such as asystole and VF may also occur. Some authors propose cardiac monitoring [15-17] after each shock, while other authors comment that it is unnecessary.[4,9,13,18] Cunningham[19] did not detect any delayed dysrhythmias in the survey sent to 56 ED directors (with 32 respondents). Purdue and Hunt[4] evaluated 48 high-voltage-related electrical accidents with normal initial ECG, and they reported that 48-h monitoring was unnecessary. Cardiac monitoring is recommended in cases where there is loss of consciousness or documented rhythm disorder at the incident site, and in cases with abnormalities occurring in the 12-lead ECG at the time of admission.

Some authors propose monitoring, claiming that myocardial injury can occur if the electrical current passed the body through the vertical axis and caused excessive cutaneous burns.[2-7] On the other hand, other authors think that if the initial 12-lead ECG is normal and there has been no loss of consciousness, it is unlikely that delayed cardiac rhythm disturbances will be seen; thus, it is not necessary to monitor the victim for 24 h.[2-13] It has been shown in a few studies that dysrhythmias could develop hours or days after the accident.

[3,4] Jensen[15] identified delayed arrhythmias 8-12 h after the accident in three cases, of which two were domestic injuries. In all these cases, the electrical current passed through the thorax. One had recurrent 304

VF, one had ventricular tachycardia (VT), and one had ventricular parasystoles. Endometrial biopsies of two patients showed patchy myocardial fibrosis and increased numbers of Na+ and K+ pumps, suggesting arrhythmogenic focus. However, researchers were not able to observe any elevation of cardiac enzymes. Due to the occurrence of these delayed arrhythmias, Jensen[15] proposed the necessity for 24-h monitoring of patients injured by electricity; however, the patients reported by Jensen had been admitted late to the ED and there had been no ECG taken immediately after the accident. Thus, it is difficult to determine whether their cardiac rhythm was normal after the incident.

It is more likely that their initial ECGs also revealed dysrhythmias. In the present study, no delayed dysrhythmias were observed regardless of the strength, duration or pathway of the current through the body.

Moreover, 36% of cases had injuries including vital organs, 33% occurred by high-voltage, 27% occurred together with trauma, 21% resulted in loss of consciousness, and 17% were accompanied by important findings such as major burns. On the basis of the results, we agree with authors that if the initial ECG of an electrically injured victim is normal and the victim is not seriously injured, delayed important dysrhythmias are unlikely to develop. Therefore, it is not necessary to inconvenience the patient, overcrowd the ED and increase the cost of care[2] by admitting this type of patient for 24-h cardiac monitoring. However, the approach to patients having existing cardiac disease is unclear. Creatine kinase (CK) and isoenzymes specific to the myocardium are not specific in determining cardiac ischemia in electrically injured patients.[5,7,20] The diagnosis of myocardial necrosis has been defined as CK elevation greater than twice the normal with a positive CK-MB fraction of >3%.[7] Depending on the skeletal muscle damage in electrical injury, CKMB can also increase.[14,21] According to some authors, the role of CK-MB in the diagnosis of myocardial injury is controversial if there is no pathognomonic ECG evidence of myocardial infarction.[5,13,21] Some authors emphasize the importance of the duration of the elevation of CK-MB levels. As the CK-MB elevations due to skeletal muscle injury will take about 1224 h, they argue that early elevations in CK-MB levels are related to the myocardial ischemia.[7] In the present study, cardiac enzyme elevations were only found in four surviving patients. However, because of the late rise in the cardiac enzymes and the lack of clinical findings compatible with ischemia, none of the cases was considered as having acute coronary syndrome.

In conclusion, cardiac rhythm problems due to electrical injuries are observed during or immediately after the event. The risk of development of a serious Temmuz - July 2012

Cardiac monitoring in patients with electrocution injury

delayed dysrhythmia is very low if the patient’s general condition is good and there is no loss of conscious, major trauma, cardiac disease, or ECG abnormalities at the time of ED admission. Therefore, it is not necessary to observe this cohort of patients for rhythm problems.

REFERENCES 1. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30:424-30.

2. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns 1997;23:576-8.

3. Solem L, Fischer RP, Strate RG. The natural history of electrical injury. J Trauma 1997;17:487-91.

4. Purdue GF, Hunt JL. Electrocardiographic monitoring after electrical injury: necessity or luxury. J Trauma 1986;26:1667.

5. Housinger TA, Green L, Shahangian S, Saffle JR, Warden GD. A prospective study of myocardial damage in electrical injuries. J Trauma 1985;25:122-4.

6. Butler ED, Gant TD. Electrical injuries, with special reference to the upper extremities. A review of 182 cases. Am J Surg 1977;134:95-101.

7. Chandra NC, Siu CO, Munster AM. Clinical predictors of myocardial damage after high voltage electrical injury. Crit Care Med 1990;18:293-7.

8. Chinnis AS, Williams JM, Treat KN. Electrical injuries. In: Emergency medicine. Tintinalli JE, Kelen GD, Stapczynski JS, editors. A comprehensive study guide. 5th ed., New York: Mc Graw Hill; 2000. p. 1292-8.

9. Bailey B, Gaudreault P, Thivierge RL, Turgeon JP. Cardiac monitoring of children with household electrical injuries.

Ann Emerg Med 1995;25:612-7.

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10. Lederer W, Kroesen G. Emergency treatment of injuries following lightning and electrical accidents. [Article in German] Anaesthesist 2005;54:1120-9.

11. Edlich RF, Farinholt HM, Winters KL, Britt LD, Long WB 3rd. Modern concepts of treatment and prevention of electrical burns. J Long Term Eff Med Implants 2005;15:511-32.

12. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical injury with a management protocol. Postgrad Med J 2002;78:283-5.

13. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006;27:439-47.

14. McBride JW, Labrosse KR, McCoy HG, Ahrenholz DH, Solem LD, Goldenberg IF. Is serum creatine kinase-MB in electrically injured patients predictive of myocardial injury?

JAMA 1986;255:764-8.

15. Jensen PJ, Thomsen PE, Bagger JP, Nørgaard A, Baandrup U. Electrical injury causing ventricular arrhythmias. Br Heart J 1987;57:279-83.

16. Kinney TJ. Myocardial infarction following electrical injury.

Ann Emerg Med 1982;11:622-5.

17. Carleton SC. Cardiac problems associated with electrical injury. Cardiol Clin 1995;13:263-6.

18. Fatovich DM, Lee KY. Household electric shocks: who should be monitored? Med J Aust 1991;155:301-3.

19. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;154:765-6.

20. Guinard JP, Chiolero R, Buchser E, Delaloye-Bischof A, Payot M, Grbic A, et al. Myocardial injury after electrical burns: short and long term study. Scand J Plast Reconstr Surg Hand Surg 1987;21:301-2.

21. Ahrenholz DH, Schubert W, Solem LD. Creatine kinase as a prognostic indicator in electrical injury. Surgery 1988;104:741-7.

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Ulus Travma Acil Cerrahi Derg 2012;18 (4):306-310

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.70194

Toraks travması sonrası hayat kurtarıcı bir uygulama: Acil serviste torakotomi A life-saving approach after thoracic trauma: Emergency room thoracotomy Tevfik İlker AKÇAM,1 Kutsal TURHAN,1 Ayşe Gül ERGÖNÜL,1 Emrah OĞUZ,2 Alpaslan ÇAKAN,1 Ufuk ÇAĞIRICI1

AMAÇ

BACKGROUND

Bu çalışmada, toraks travması sonrası hastanemiz acil servisine (AS) getirilen ve yapılan girişim sırasında kalp ve/ veya solunumu duran hastalarda, acil serviste uygulanan resüsitatif torakotominin endikasyonları, yöntemi ve sonuçları tartışıldı.

In this article, the outcomes, indications and methods of emergency department service resuscitative thoracotomy in cardiac and/or respiratory arrest patients after thoracic trauma are discussed.

GEREÇ VE YÖNTEM

Ocak 2004 ile Aralık 2010 tarihleri arasında toraks travması sonrası AS’de dokuz hastaya resüsitatif torakotomi uygulandı. Hasta verileri geriye dönük olarak incelendi.

Between January 2004 and December 2010, nine resuscitative thoracotomies were performed after thoracic trauma in the emergency department of our hospital. The records of the patients were evaluated retrospectively.

BULGULAR

RESULTS

METHODS

Dokuz hastaya AS koşullarında girişim yapıldı; beşi kesici delici alet yaralanması, ikisi trafik kazası, birer hasta yüksekten düşme ve ateşli silah yaralanması nedenliydi. Tüm hastalara sırtüstü pozisyonda anterolateral torakotomi uygulandı. Üç hastada akciğer parankimal laserasyonu, üç hastada kardiyak laserasyon, diğer iki hastada interkostal damarlar yaralanması ve bir hastada ise inen aortada laserasyon vardı. Etyolojisinde künt travma olan dört hasta kaybedildi, penetran travma nedeniyle resüsitatif torakotomi uygulanan beş hastanın üçü ortalama sekiz gün izlem sonrasında şifa ile taburcu edildi, diğer ikisi ameliyatta kaybedildi.

A total of nine patients underwent resuscitative thoracotomy: five stab wounds, two traffic accidents, one fall from height, and one gunshot wound. Anterolateral thoracotomy in supine position was performed in all. Three patients had lung parenchymal laceration, three patients had cardiac laceration, two patients had intercostal vessel injury, and one patient had descending aorta injury. None of the four patients with blunt trauma recovered. Three of five patients with penetrating trauma were discharged after an average of eight days of follow-up, whereas two of them were lost perioperatively.

SONUÇ

CONCLUSION

AS koşullarında resüsitatif torakotomi uygulanan hastalar, travma sonrası şok halindedir, büyük oranda sıvı ve kan infüzyonu yapılmasına karşın hipotansiyonu kontrol altına alınamayan ve ameliyat salonuna nakil için vakit kaybına tahammülü olmayan hastalardır. Penetran travmalı hastaların sonuçları künt toraks travmalı hastalara göre daha iyidir.

Emergency room thoracotomy can be performed in thoracic trauma cases who are in shock and have unresponsive hypotension despite large volume fluid and blood replacement and no time for transportation to the operating room.

The results are better in penetrating trauma patients than in blunt trauma.

Anahtar Sözcükler: Acil servis torakotomisi; resüsitatif torakotomi; toraks travması.

Key Words: Emergency room thoracotomy; resuscitative thoracotomy; thoracic trauma.

Bu çalışmanın bir bölümü European Respiratory Society (ERS) Kongresi’nde sunulmuştur (18-22 Eylül 2010, Barselona, İspanya).

A part of this study presented at the (ERS) European Respiratory Society 2010 Annual Congress (September 18-22, 2010, Barcelona, Spain).

Ege Üniversitesi Tıp Fakültesi, 1Göğüs Cerrahisi Anabilim Dalı, 2 Kalp Damar Cerrahisi Anabilim Dalı, İzmir.

Departments of Thoracic Surgery, Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey.

İletişim (Correspondence): Dr. Tevfik İlker Akçam. Ege Üniversitesi Tıp Fakültesi Göğüs Cerrahisi Anabilim Dalı, İzmir, Turkey.

Tel: +90 - 232 - 390 49 19 e-posta (e-mail): tevfikilkerakcam@hotmail.com

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Acil serviste torakotomi

Yaşamın kırk yılında en sık ölüm nedeni travmalardır, bu ölümlerin %20-25’inin nedeni toraks travmalarıdır.[1-2] Toraks travmaları sonrası genellikle izlem ya da tüp torakostomi yeterli olabilse de hastaların bir kısmında acil ya da elektif operasyon gerekliliği doğmaktadır. Nadiren, yaşam kurtarıcı bir girişim olarak acil servis torakotomisi (AST) zorunlu hale gelebilir.[3] Günümüzde travma sonrası zaman kaybetmeden hastanelere hızlı erişimin sağlanmasındaki kolaylıklar nedeniyle, genel durumu kötü, nabız ve solunumu durma aşamasında hastaneye ulaştırılan hasta sayısı artmaktadır.[4] Bunun sonucunda, bu türdeki hastalara uygulanabilecek işlemlerden biri olan AST’nin endikasyonları ve uygulama yöntemleri konusunda çalışmalar yapılmaktadır.[3,5-7] Bu yazıda, toraks travması sonrası acil serviste resüsitatif torakotomi uygulamasının yarar ve gerekliliğinin değerlendirilmesi amaçlandı, kliniğimiz tarafından bu amaçla acil serviste yapılan torakotomiler, literatür eşliğinde tartışıldı.

GEREÇ VE YÖNTEM Ocak 2004 ile Aralık 2010 tarihleri arasında penetran ya da künt toraks travması nedeniyle acil servise kalp ve/veya solunum durmasıyla getirilen veya acil serviste kalp veya solunumu duran 9 hastaya AST uygulandı. Hastaların tıbbi kayıtları geriye dönük olarak incelendi. Yaşı, cinsiyeti, yaralanma şekli, majör travma bölgesi, toraks travmasına eşlik eden diğer patolojileri, hastanede kalış süreleri ve uygulanan cerrahi yöntem kaydedildi (Tablo 1).

Hastaların tümü acil serviste değerlendirildi. Ayrıntılı fizik bakısı hızlıca tamamlandı. Tüm hastalar entübe edilip, monitöre bağlandı, en az iki adet intravenöz kateterizasyon uygulandı. Biyokimya ve arteriyel kan gazı için örnekler alındı. Uygun infüzyona (eritrosit süspansiyonu, tam kan, taze donmuş plazma ve diğer kolloid ve kristaloid intravenöz sıvılar) süratle başlandı. Yatak başı ön-arka akciğer grafisi çekildi.

Acil servise getirildiklerindeki fizyolojik durumlarına göre kategorilere ayrıldı (Tablo 2).[6,8,9]

Tablo 2. Olguların fizyolojik durum sınıflaması Kategori Fizyolojik durum

I

II

III IV

Yaşam bulgusu olmayan; herhangi bir refleks alınamayan Agoni; nabzı ve kan basıncı alınamayan, EKG’de elektriksel aktivite var Derin şok; sistolik kan basıncı 60 mmHg’nin altında Orta dereceli şok; sistolik kan basıncı 60-90 mmHg arasında

Hastalarda masif hemotoraks bulunduğu anlaşılması üzerine sırtüstü pozisyonda (Şekil 1a) anterolateral torakotomi uygulandı.[5,10] Sırtüstü yatış pozisyonu ek patolojilere yaklaşım ve diğer tıbbi girişimlere imkan vermek amacıyla hastalara verilebilecek en uygun pozisyon olduğu düşünüldü. Tüm torakotomiler 4. interkostal aralıktan, sternumdan başlayıp, posterior aksiller çizgiye kadar uzanan aksta uygulandı. Böylelikle bu insizyon ile, aortaya kros klemp konulmasına, açık kardiyak masaj yapılabilmesine, kalp, akciğer, ya da büyük damar yaralanmalarına girişim olanağı öngörüldü. Hastaların hepsi tek lümenli entübasyon tüpüyle entübe edildikleri için, interkostal kas kesilmeden önce, toraks içinde herhangi bir yapıya hasar vermemek amacıyla, ventilasyon kısa bir süre durduruldu. Toraks kavitesine girdikten sonra iki kosta arasına ekartör yerleştirildi. Eksplorasyonda ilk görülen masif kan ve koagulum boşaltıldıktan sonra majör yaralanma bölgesi araştırıldı.

BULGULAR Altısı erkek, üçü kadın hastanın yaş ortalaması 34,8±10,4 (dağılım, 19-47 yaş) idi. Beş hasta kesicidelici alet yaralanması (KDAY) sonucunda, iki hasta trafik kazası sonrasında, birer hasta da ateşli silah yaralanması ve yüksekten düşme sonucunda acil servise getirilmişti. İlk değerlendirmede fizyolojik durumlarına göre hastaların 5’inin kategori 2’de, diğer 4’ünün ise kate-

Tablo 1. Demografik ve klinik veriler No Yaş Cinsiyet Yaralanma yeri

Travmanın oluş şekli Sonuç

Ek patoloji

1 2 3 4 5 6 7 8 9

KDAY Sekelsiz sağkalım KDAY Sekelsiz sağkalım KDAY Sekelsiz sağkalım KDAY Girişimde ölüm KDAY Girişimde ölüm Trafik kazası Girişimde ölüm Trafik kazası Girişimde ölüm Yüksekten düşme Girişimde ölüm Ateşli silah yaralanması Girişimde ölüm

Karın ve sol bacakta kesi Ellerde kesi Karında kesi – – Ekstremite kırığı Kraniyal patoloji Ekstremite kırığı –

36 21 30 45 30 43 43 19 47

Kadın Kadın Erkek Erkek Erkek Erkek Erkek Kadın Erkek

Sol ventrikül Akciğer parankimi Akciğer parankimi Sol ventrikül Sol ventrikül Toraks duvarı Toraks duvarı İnen aort Akciğer parankimi

KDAY: Kesici delici alet yaralanması.

Cilt - Vol. 18 Sayı - No. 4

307

Ulus Travma Acil Cerrahi Derg

(a)

(b)

Şekil 1. (a) Sırtüstü pozisyonda anteolateral torakotomi. (b) Akciğer parankim yaralanması.

gori 3’de yer aldığı anlaşıldı. Ancak, olguların tümünde acil servise getirildikten kısa bir süre sonra içinde arrest geliştiği izlendi.

Hiçbir gecikmeye neden olmadan yapılan bu değerlendirme işlemlerinin sonunda patoloji bulunan hemitoraks belirlenerek gecikmeksizin acil servis koşullarında anterolateral torakotomi uygulandı. Yapılan eksplorasyonda; üç hastada ventrikül yaralanması, üç hastada akciğer parankim yaralanması (Şekil 1b), iki hastada yaygın göğüs duvarı yaralanması (özellikle interkostal vasküler yapı yaralanmasıyla birlikte), bir hastada ise aortada yaralanma olduğu görüldü.

KDAY sonucu üç ventrikül, iki hastada ise akciğer parankim yaralanması saptandı. KDAY’ye maruz kalan hastaların ikisinde ek başka bir patolojiye rastlanmaz iken, birinde karın ve sol bacakta, birinde sadece karında, birinde ise ellerde kesi olduğu izlendi. Bu ek yaralanmalar, kalp ve akciğer dolaşımını bozacak düzeyde değildi.

Trafik kazası sonrası meydana gelen yaralanmaların özellikle göğüs duvarında, travmanın şiddetine bağlı olarak ağır deformasyon ve işlev kaybı yarattığı, bunun sonucunda da kosta, interkostal vasküler yapılar, göğüs duvarı kasları ve diğer göğüs duvarı yumuşak dokularında hasar oluşturduğu izlendi. Bu iki hastanın birinde, tarif edilen torakal patolojilere ek olarak ekstremite kırıkları, diğerinde ise kuşkulu kraniyal patoloji olduğu izlendi. Bu hasta girişim sırasında kaybedildiği için, kraniyal patolojinin hastanın yaşamını tehlikeye atıp atmadığı konusunda bilgi sahibi olunamadı. Yüksekten düşme nedeniyle girişimde bulunulan hastada aortada yırtık ve ekstremite kırıkları görülürken, ateşli silah yaralanması bulunan diğer hastada ise akciğer parankim yaralanması dışında ek patoloji saptanmadı.

Uygulanan resüsütatif torakotomi sonunda dokuz hastanın altısı girişim sırasında kaybedildi. Bu altı hastanın tümüne en az 15 dakika süren internal kardiyak masaj uygulandı. Kardiyak masaj esnasında ka308

nama kontrolü sağlanmaya çalışıldı. Kanama kontrolü sağlansa da, daha önce kaybettikleri aşırı miktardaki kan nedeniyle internal kardiyak masaja yanıt vermeyen bu hastalar kaybedildi. Kaybedilen hastalardan ikisinde KDAY’ye bağlı ventrikül yaralanması vardı.

Bu hastalardaki ventrikül harabiyeti, çift taraflı, yani giriş ve çıkış delikleri olan yaralanmalardı ki anteriordaki alana müdahalede zorluk yaşanmaz iken, posteriora ulaşmada ve tamir işleminde güçlükle karşılaşıldı.

Trafik kazası sonrası girişimde bulunulan iki hastada ise toraks bölgesinde yaygın, çok odaklı bir yaralanma söz konusuydu. Torakotomi sonrasındaki eksplorasyonda çok sayıda interkostal damarın yanında mamarian arterin de yaralandığı izlendi. Bu bölgelerin tümüne girişim yapıldıysa da hastalar kurtarılamadı.

Yüksekten düşme olgusunda inen aortada parçalanma tarzında yırtılma izlendi, ateşli silah yaralanması olgusunda akciğer parankiminde geniş hasarın yanında pulmoner arter yaralanması vardı. Bu iki olgu da girişim sırasında kaybedildi.

KDAY nedeniyle girişimde bulunulan diğer üç hastanın ikisinde akciğer parankiminde, birinde sol ventrikül yaralanması saptandı. Bu hastalara yapılan ilk girişimde kanama kontrol alındıktan sonra hastaların kalp atışlarının tekrar geri geldiği izlenmesi üzerine hastalar operasyonun geri kalanın tamamlanması açısından acil servisten ameliyathaneye nakledildi. Operasyonları tamamlanan ve herhangi bir rezeksiyona gerek kalmadan primer onarımın yeterli olduğu hastalar ortalama 8,3±5,3 gün (dağılım, 4-14 gün) hastane izleminin ardından, cerrahi şifa ile eksterne edildiler.

TARTIŞMA AST, toraks travması sonrasında acil servise getirilen kalp ve/veya solunumu duran hastalara acil serviste uygulanan torakotomi işlemidir. Ancak, bu operasyon genel durumu giderek kötüleşen, yaşanan olaydan saatler sonra yapılan girişimere yanıt vermeyen ve bu nedenle operasyona alınmak zorunda kalınan hastalara uygulanan işlem ile karıştırılmamalıdır.[6,11,12] ÖnceTemmuz - July 2012

Acil serviste torakotomi

leri açık kalp masajı yapmak için kullanılan bu yöntem, ilk kez 1967 yılında Beall ve arkadaşları[13] tarafından göğüs travmalı, ölmek üzere olan bir hastaya uygulanmıştır. Hızlı transport ve uygun nakil sitemleri ile acil servislere ulaşan hasta sayısının artmasıyla, AST’nin uygulanımı ile gerekliliğini tartışmaya açan pek çok çalışma yapılmıştır.[4-6,12,14] Endikasyonları standardize etmek kolay olmadığı gibi tanımlamalarda bir karışıklık da göze çarpmaktadır. Bu açıdan bakıldığında, değerlendirilmesi gereken ilk parametre hastanın genel durumu ve hayati bulgularıdır. Hastanemizde olduğu gibi acil servis ile ameliyathane arasında, hasta için yaşamsal önem arz eden miktarda sürenin kaybedildiği bir mesafe söz konusu ise, bu kritik dakikaların çok etkin değerlendirilmesi gerekir. Mattox ve arkadaşları,[15] bu konuda yapmış oldukları çalışmada ameliyathaneye ulaşımda kaybedilecek zamanın, bu tür hastalar için yaşamsal önem taşıdığını bildirmişlerdir. Bu nedenle AST’nin bilinen endikasyonları arasında bulunan, penetran kardiyotorasik yaralanmalı agonik hastaların resüsitasyonu, perikardiyal tamponadın boşaltılması, torasik kavitedeki kanamanın kontrolü, etkin internal kalp masajı yapılması, masif hava embolisinin tedavisi, kalp yaralanmasının tamiri, pulmoner hilus ve inen torasik aort klampajı gibi uygulamalar hızlı bir şekilde akla getirilmeli ve AST uygulaması geciktirilmemelidir.[3,6,16] Özellikle sıvı replasmanı başlanan hastalarda sıvı replasmanının cevabı beklenmeden AST uygulanmalıdır.[17] Nabzın, kendiliğinden solunumun, pupiller reaktivitenin ve monitörize kardiyak aktivitenin olmadığı künt travmalı olgularda, kardiyak aktivitesi olup kardiyak masaj ile desteklenen ve resüsitasyon süresi acil servise varıştan 5 dakikadan daha fazla olan künt toraks travmalı olgularda AST’nin gereksiz olduğu bildirilmektedir.[9,14,18] Benzer şekilde, penetran travma nedeniyle acil servise getirilmeden önce 15 dakikadan daha uzun süre kardiyopulmoner resüsitasyon uygulananlarda da AST’nin bir yarar sağlamadığı vurgulanmaktadır.[12] AST kararı verme ve bunu uygulama zor ve ani karar gerektiren bir durumdur. Çünkü bazı çalışmalarda acil serviste yapılan girişimin, ameliyathanede yapılan operasyona göre daha düşük sağkalımla sonuçlandığı bildirilmektedir.[19] Künt toraks travmasına sekonder uygulanan AST sonucunda, nörolojik sekelsiz uzun sağkalım süresinin, penetran travma sonrasında uygulananlara göre daha düşük olduğu yayınlanmıştır.[9,20] Çalışmamızda da penetran travmalı 6 hastanın 3’ünde sekelsiz uzun süreli sağkalım elde edilirken, künt travmalı hastaların tümü kaybedilmiştir. Penetran toraks yaralanmalı olgulara uygulanan AST’lerin karşılaştırıldığı çalışmalarda, sağkalımın KDAY’li hastalarda ateşli silah yaralanmalarına göre daha uzun olduğu izlenmiştir.[21,22] KDAY’li olgular içinde de izole kalp yaralanmasının Cilt - Vol. 18 Sayı - No. 4

AST için en yüksek oranda yapılan yaralanma çeşidi olduğu da belirtilmektedir.[22] Sonuç olarak, AST acil servise kısa bir süre önce kalp veya solunumu durarak getirilen ya da acil servis gözleminde kalp ve solunumu duran hastalarda, ameliyathaneye uzak veya ulaşılamaz olduğu durumlarda endikedir. Özellikle penetran, KDAY sonrası oluşmuş olan bir travma söz konusu ise endikasyon konduğu takdirde bu işlemin beklenmeden uygulanması gerekir. Son zamanlarda hızla gelişen hasta nakil sistemleri göz önüne alındığında, acil servislerde bununla ilgili olarak yetişmiş ve bilgilendirilmiş personel varlığı yanında, gerekli operasyon malzemelerinin de hazır tutulması AST sonuçlarını olumlu yönde değiştirecektir.

Teşekkür Çizimlerdeki katkıları için Dr. Ozan F. Sarıkaya’ya teşekkür ederiz.

KAYNAKLAR 1. MacKenzie EJ, Fowler CJ. Epidemiology. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed., New York: McGraw-Hill; 2000. p. 21.

2. LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma.

Surg Clin North Am 1989;69:15-9.

3. Eryilmaz M, Ozdoğan M, Ağalar HF. Remarks of 52 physicians participating into 8th Ankara Emergency Rooms (ERs) Meeting 2005 on resuscitative thoracotomy intervention.

Ulus Travma Acil Cerrahi Derg 2006;12:201-8.

4. Kidak L, Sofuoğlu T, Keskinoğlu P, Olmezoğlu Z. A motivating experience for emergency medical services: the first Turkish Ambulance Rally. Ulus Travma Acil Cerrahi Derg 2009;15:584-90.

5. Biffl WL, Moore EE. Resuscitative thoracotomy. Operative Techniques in General Surgery 2000;2:168-75.

6. Ülkü R. Toraks travmalı hastada acil departman torakotomisi ve tüp torakostomisi. Toraks Cerrahisi Bülteni 2010;1:19-28.

7. Mollberg NM, Glenn C, John J, Wise SR, Sullivan R, Vafa A, et al. Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon. Ann Thorac Surg 2011;92:455-61.

8. Uludağ M, Yetkin G, Celayir F, Citgez B, Başaran C, Baykan A. Penetrating cardiac injuries. Ulus Travma Acil Cerrahi Derg 2007;13:199-204.

9. Brown SE, Gomez GA, Jacobson LE, Scherer T 3rd, McMillan RA. Penetrating chest trauma: should indications for emergency room thoracotomy be limited? Am Surg 1996;62:530-4.

10. Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: “how to do it”. Emerg Med J 2005;22:22-4.

11. Søreide K, Søiland H, Lossius HM, Vetrhus M, Søreide JA, Søreide E. Resuscitative emergency thoracotomy in a Scandinavian trauma hospital--is it justified? Injury 2007;38:3442.

12. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg 2006;1:4.

13. Biffl WL, Moore EE, Harken AH. Emergency department thoracotomy. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed., New York: McGraw-Hill; 2000. p. 245.

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14. Baxter BT, Moore EE, Moore JB, Cleveland HC, McCroskey BL, Moore FA. Emergency department thoracotomy following injury: critical determinants for patient salvage. World J Surg 1988;12:671-5.

15. Mattox KL, Beall AC Jr, Jordan GL Jr, De Bakey ME. Cardiorrhaphy in the emergency center. J Thorac Cardiovasc Surg 1974;68:886-95.

16. Crumpton KL, Shockley LW. Emergency department thoracotomy. Available from: http://www.thrombosis-consult. com/articles/Textbook/127_thoracotomy.htm.

17. Gao JM, Gao YH, Wei GB, Liu GL, Tian XY, Hu P, et al.

Penetrating cardiac wounds: principles for surgical management. World J Surg 2004;28:1025-9.

18. Bodai BI, Smith JP, Blaisdell FW. The role of emergency

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thoracotomy in blunt trauma. J Trauma 1982;22:487-91.

19. Bleetman A, Kasem H, Crawford R. Review of emergency thoracotomy for chest injuries in patients attending a UK Accident and Emergency department. Injury 1996;27:129-32.

20. Kavolius J, Golocovsky M, Champion HR. Predictors of outcome in patients who have sustained trauma and who undergo emergency thoracotomy. Arch Surg 1993;128:1158-62.

21. Feliciano DV, Bitondo CG, Cruse PA, Mattox KL, Burch JM, Beall AC Jr, et al. Liberal use of emergency center thoracotomy. Am J Surg 1986;152:654-9.

22. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg 2000;190:288-98.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):311-316

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.36418

Is total-subtotal colectomy and primary anastomosis a good treatment alternative in malignant obstructive lesions of the left colon?

Sol kolonun tıkayıcı malign lezyonlarında total-subtotal kolektomi ve primer anostomoz iyi bir tedavi alternatifi midir?

Kemal ARSLAN, Mehmet Ali ERYILMAZ, Ahmet OKUŞ, Osman DOĞRU, Ömer KARAHAN, Hande KÖKSAL BACKGROUND

AMAÇ

This study was designed in order to compare the effectiveness of subtotal-total colectomy with other surgical methods in the treatment of malignant obstructive lesions of the left colon.

Bu çalışmada, sol kolonun tıkayıcı malign lezyonlarında total-subtotal kolektomi anostomoz ile diğer cerrahi tedavi yöntemleri karşılaştırıldı.

METHODS

Çalışmaya Konya Eğitim ve Araştırma Hastanesine 20042007 yılları arasında transvers kolon distalinde tıkanıklık bulguları ile başvuran ve cerrahi tedavi uygulanan hastalar dahil edildi. Hastalar cerrahi prosedüre göre üç gruba ayrıldı. Bunlar: Grup I: Hartmann prosedürü; Grup II: Rezeksiyon, anostomoz ve saptırıcı ileostomi; Grup III: Total veya subtotal kolektomi ve primer anastomoz. Hastaların dosyaları geriye dönük olarak incelendi.

Patients admitting with symptoms of colonic obstruction and treated by emergency surgery in Konya Education and Research Hospital between 2004 and 2007 were enrolled.

Patients were divided into three groups according to the surgical procedures (Group I: Hartmann procedure; Group II: resection + diverting ileostomy; Group III: total-subtotal colectomy). Related patient data were evaluated retrospectively.

GEREÇ VE YÖNTEM

BULGULAR

The mean age of 62 patients was 64 (38-89) years. There were no significant differences between the groups with respect to gender, age, American Society of Anesthesiology scores, and tumor stages. There were no significant differences between the study groups in terms of operative duration, postoperative mortality, and five-year survival; however, the length of hospital stay and hospitalization costs were lower in Group III compared to the other groups.

Altmış iki hastanın yaş ortalaması 64 (dağılım, 38-89 yaş) idi. Birinci grupta 15, ikinci grupta 21, üçüncü grupta 26 hasta vardı. Gruplar arasında yaş ortalamaları, cinsiyet, ASA skoru ve tümör evresi bakımından anlamlı fark yoktu. Çalışma grupları arasında ameliyat süresi ve ameliyat sonrası morbidite, mortalite ve beş yıllık sağkalım açısından anlamlı fark yoktu, ancak hastanede kalma süresi ve tedavi maliyetleri açısından Grup I ve Grup II’ye göre Grup III’de anlamlı olarak düşüktü.

CONCLUSION

SONUÇ

RESULTS

We suggest that subtotal-total colectomy performed by experienced surgeons may be a good alternative to the other procedures.

Deneyimli cerrahlar tarafından yapılan total-subtotal kolektomi ve primer anostomozun diğer bir veya iki aşmalı cerrahi prosedürlere göre daha iyi bir alternatiftir.

Key Words: Treatment of obstructive lesions of the left colon; total or subtotal colectomy; Hartmann procedure; resection; diverting ileostomy.

Anahtar Sözcükler: Sol kolon tıkayıcı tümörlerinin tedavisi, total veya subtotal kolektomi; Hartmann prosedürü; rezeksiyon; saptırıcı ileostomi.

Departments of General Surgery, Konya Training and Research Hospital, Konya, Turkey.

Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Klinikleri, Konya.

Correspondence (İletişim): Kemal Arslan, M.D. Necip Fazıl Mah., Ateşbazı Sok., Meram Yeniyol, 42040 Konya, Turkey.

Tel: +90 - 332 - 323 67 09 e-mail (e-posta): arslanka74@hotmail.com

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Ulus Travma Acil Cerrahi Derg

Being the second most common cancer in men and third most common in women, colorectal cancer reaches a peak incidence in the sixth and seventh decades.

More than half of these cancers are localized on the left side, which is also the most frequent anatomical localization of colon cancers in general.[1] Right-sided tumors constitute about a quarter of all colon cancers, while synchronous disease may be observed in 5% of the patients. Localization in the splenic flexure is observed in 4% of the patients, but this rarest localization is associated with obstruction in half of the cases.

[2] Admission with acute obstruction in patients with colon cancers has been reported at rates up to 29% in different series.[3,4] The most frequent etiological factor in emergent colonic surgeries is malignancies, constituting approximately 60% of all mechanical obstructions.[5] Emergent surgery in colorectal cancers has been reported to be associated with high mortality and morbidity rates.[6,7] Several surgical procedures have been described for the treatment of obstructive lesions of the left colon; however, there is no consensus on a particular method to be used for the surgical management of acute obstructions due to malignancies.[8,9] The classical three-step surgical approach including initial transverse loop colostomy followed by left colectomy performed after improvement in the patientâ&#x20AC;&#x2122;s general status and closure by colostomy after two or three weeks has started to be replaced with the more aggressive single-step emergent surgery as subtotal colectomy and primary anastomosis.[10,11] Other surgical alternatives include Hartmann resection, intraoperative colonic lavage and primary anastomosis following resection[12] and Mikulicz resection followed by closure via colostomy.[13] The use of rectosigmoid stent as an alternative to initial surgical decompression is currently at an experimental stage.[14] It has been reported in several studies that single-step procedures are more advantageous compared with multi-step procedures in the surgical management of obstructive malignancies of the left colon in terms of short- and long-term survival.[10,11,15-17] This study was designed in order to compare the effectiveness of emergent subtotal-total colectomy and primary anastomosis with other surgical methods in the treatment of malignant obstructive lesions of the left colon.

MATERIALS AND METHODS Records of patients admitting with symptoms of colonic obstruction and treated by emergent surgery in the General Surgery Clinic of Konya Training and Research Hospital between January 2004 and March 2007 were evaluated retrospectively. Patients with tumors localized in the distal transverse colon and be312

yond were considered as left colonic obstructive tumors.

Demographic characteristics, comorbidities, colonic obstruction level, surgical procedures, operative duration, length of hospital stay, postoperative morbidity and mortality, and five-year survival rates were evaluated. Hospitalization costs were calculated based on prices set by the Social Security Institution. Definitive pathological stages of the patients according to tumor-node-metastasis (TNM) staging system were determined based on pathology reports. Related patient data were retrieved from patient files and hospital computer records. Patients with insufficient information in their files, those undergoing colostomy without resection and those with rectal obstruction were excluded.

Patients were allocated into three groups according to the surgical procedures (Group I: Hartmann procedure; Group II: resection, anastomosis + diverting ileostomy; Group III: total or subtotal colectomy and primary anastomosis). The three groups were compared in terms of postoperative mortality, morbidity, operative duration, length of hospital stay, and treatment costs.

Statistical Analysis Statistical analyses were performed using the Statistical Package for the Social Sciences version 13.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were performed and the results were presented as number, mean, median, and range. Categorical variables were compared using chi-square test, and numeric variables were compared between the groups using Mann-Whitney U test. A p value of <0.05 was considered statistically significant.

RESULTS Records of 76 patients treated by emergent surgical resection due to malignant colonic obstruction were examined. In 62 patients, the tumor was localized in the distal transverse colon and beyond. The number of patients, gender distribution and median age according to the three surgical procedure groups are presented in Table 1. The mean age of the patients was 64 years (range 38 to 89 years). There were no significant differences between the groups with respect to gender and age.

The distribution of patients according to comorbidities, American Society of Anesthesiology (ASA) scores, and tumor stages in the study groups are presented in Table 2. There were no significant differences between the groups with respect to comorbidities, ASA scores, and tumor stages.

The distribution of patients with respect to postoperative complications according to study groups is Temmuz - July 2012

Total-subtotal colectomy and primary anastomosis

Table 1. The number of patients, gender distribution and median age according to

the three surgical procedure groups

Patients Male/Female Median age (Years)

Group I

Group II

Group III

p

15 10/5 64 (40-89)

21 13/8 66 (38-87)

26 16/10 62 (45-85)

0.275 0.192

p>0.05, not significant; Data are given in numbers (ranges).

Table 2. The distribution of patients according to comorbidities, American Society of Anesthesiology scores, and tumor stages

Heart disease Diabetes mellitus Pulmonary disease Renal failure Total ASA Scores I II III IV TNM Stages I II III IV

Group I (n=15)

Group II (n=21)

Group III (n=26)

11 3 6 2 22

– 3 11 2

– 6 5 4

7 6 12 – 24

– 4 14 3

– 9 9 3

12 7 11 1 31

– 5 17 4

– 9 10 7

p

0.872

0.951

0.847

ASA: American Society of Anesthesiology; TNM: tumor-node-metastasis.

Table 3. The distribution of patients with respect to postoperative complications

according to study groups

Wound infection Eventration/evisceration Anastomotic leak Anastomotic hemorrhage Relaparotomy Pulmonary infection Surgical mortality

Group I (n=15)

Group II (n=21)

Group III (n=26)

p

4 3 – – 3 1 4

4 2 1 1 1 2 4

5 – 1 1 – 3 3

0.72 0.12 0.09 0.09 0.21 0.60 0.65

presented in Table 3. There were no significant differences between the groups with respect to postoperative complications. Wound infection rates, re-laparotomy rates and morbidity rates related with evisceration were higher in Groups I and II when compared with Group III, but the difference was not significant statistically.

Operative duration, postoperative mortality, length of hospital stay, hospitalization costs, and five-year Cilt - Vol. 18 Sayı - No. 4

survival rates are presented in Table 4. There were no significant differences between the study groups in terms of operative duration, postoperative mortality and five-year survival rates (p>0.05). Although it was not statistically significant, the five-year survival rate was higher in Group III, and we think that this difference may be related with the stoma-related complications in Groups I and II. However, significant differences were observed regarding the length of hospital stay and hospitalization costs (p=0.04 and p=0.04, 313

Ulus Travma Acil Cerrahi Derg

Table 4. Operative duration, postoperative mortality, length of hospital stay, hospitalization costs, and five-year survival rates

Operative duration (min) Length of hospital stay (days) Postoperative mortality, n (%) Hospitalization cost (TL)* 5-year survival, n (%)

Group I (n=15)

Group II (n=21)

Group III (n=26)

p

215 (160-350) 17.2 4 (26.7) 9.421 5 (20)

235 (170-360) 18.6 5(23.8) 10.125 8 (38.1)

225 (150-325) 11.3 6 (23.1) 6.642 14 (53.8)

0.23 0.04 0.966 0.04 0.366

*Based on prices set by the Social Security Institution; TL: Turkish lira.

respectively). The length of hospital stay and hospitalization costs were lower in Group III compared with Groups I and II.

DISCUSSION Emergent surgical procedures are required due to intestinal obstruction in approximately 20% of colorectal cancers.[18] Emergent surgery is associated with high morbidity and mortality rates in patients with distended and unprepared bowel.[19] Several surgical procedures have been used and studied in the management of malignant colonic obstructions, but recently, the classical approaches are increasingly being replaced by single-step subtotal or total colectomy involving resection and primary anastomosis with or without colonic irrigation.[20-24] The need for stoma, which is often left open due to lack of opportunity for closure, is eliminated in these single-step procedures, which are also associated with lower mortality and morbidity rates.[10,11,15-17] This study was designed in order to compare the effectiveness of emergent subtotaltotal colectomy and primary anastomosis with other surgical methods in the emergent treatment of malignant obstructive lesions of the left colon.

Colon cancers manifest by colonic obstruction in approximately 30% of the patients.[3,4] In the present study, the rate of emergent surgery due to obstruction was noted as 19.38%. Moreover, the left colonic malignant obstruction rate was 81.6% in our study.

Targownik et al.[25] reported this rate as ranging from 65-90% in their series. The reasons why malignant obstructions mostly occur in the left colon, especially in the splenic flexure, include increased fecal stiffness, anatomical features of the region, and narrower diameter of the left colon compared to the right colon.

Resection and primary anastomosis is performed with increasing frequency in the management of obstructive lesions of the left colon. It can be performed either directly or together with intraoperative colonic lavage.

Thus, complications caused by multiple surgeries can be avoided. It has been shown that intraoperative colonic lavage prolongs operative duration and does not lower the incidence of anastomosis leak.[7] Intralumi314

nal fecal loading and the difference between the proximal and distal colon diameters renders difficulty in terms of anastomosis technique in patients treated by resection and primary anastomosis.[26,27] An increased incidence of anastomosis leak, which is the most significant disadvantage, has currently been reported within 1-7% in several studies, and the mortality rate has been reported to be 2-9%.[25] In our clinic, we prefer to perform a colostomy in patients with resection and anastomosis in order to lower the morbidity and mortality rates related with anastomosis leakage. In the present study, anastomosis leak was noted in one patient undergoing resection, primary anastomosis and diverting ileostomy and in one patient undergoing subtotal-total colectomy; it closed spontaneously without any need for intervention. Many studies comparing two-step procedures requiring colostomy and resection plus primary anastomosis have demonstrated that length of hospital stay was longer, morbidity was higher, and survival was lower in the two-step procedures.[27] Another treatment alternative in obstructive lesions of the left colon is total-subtotal colectomy plus anastomosis between the ileum and rectum or sigmoid colon. The tumor can be resected in a single session and stoma complications can be avoided.

In some studies, it has been shown that this surgical procedure has an advantage in treating synchronous tumors (11%) in a single step.[26,27] In this way, the anastomosis between the ileum and rectum/sigmoid colon can be performed with a good technique without contaminating the abdominal cavity. In emergent surgeries, the leakage risk was higher in colo-colonic anastomosis than in ileocolic anastomosis.[27,28] The longer operation time, postoperative diarrhea and incontinence in elderly patients are the disadvantages of the procedure.[7,27] In most of the patients, the diarrhea resolves spontaneously or with medical treatment in a few months.[26,27] Reported complication rates associated with this technique in several series are from 2-8% for anastomosis leakage, 10-21% for morbidity, and 0-10% for Temmuz - July 2012

Total-subtotal colectomy and primary anastomosis

mortality, which are all lower than with multi-step procedure alternatives.[26,29,30] As a result, as concluded in this study, total/subtotal colectomy can be a good alternative with low morbidity and mortality rates in selected patients when performed by experienced surgeons.[26,28] Another treatment method that is used in malignant colonic obstructions is placement of a self-expandable stent inside the tumor to enable passage.[25,27] As this procedure was not being performed in our center during the period of this study, data regarding this procedure was not available.

Subtotal-total colectomy combined with primary anastomosis was found to be associated with a shorter hospital stay and lower hospitalization costs in the treatment of malignant obstructions of the left colon.

Considering the potential existence of a synchronous tumor or polyp, we suggest that subtotal-total colectomy and primary anastomosis performed by experienced surgeons may be a good alternative to other one- or two-step procedures. This technique provides an opportunity for a safer primary anastomosis to be performed without intraabdominal contamination in selected cases.

REFERENCES 1. McCullough JA, Engledow AH. Treatment options in obstructed left-sided colonic cancer. Clin Oncol (R Coll Radiol) 2010;22:764-70.

2. Aldridge MC, Phillips RK, Hittinger R, Fry JS, Fielding LP. Influence of tumour site on presentation, management and subsequent outcome in large bowel cancer. Br J Surg 1986;73:663-70.

3. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD; Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer.

Ann Surg 2004;240:76-81.

4. Ohman U. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742-7.

5. Baron TH, Kozarek RA. Endoscopic stenting of colonic tumours. Best Pract Res Clin Gastroenterol 2004;18:20929.

6. Alvarez JA, Baldonedo RF, Bear IG, Truán N, Pire G, Alvarez P. Obstructing colorectal carcinoma: outcome and risk factors for morbidity and mortality. Dig Surg 2005;22:17481.

7. Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl 2008;90:181-6.

8. Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol 2004;13:14957.

9. De Salvo GL, Gava C, Pucciarelli S, Lise M. Curative surgery for obstruction from primary left colorectal carcinoma: primary or staged resection? Cochrane Database Syst Rev 2002;(1):CD002101.

10. Halevy A, Levi J, Orda R. Emergency subtotal colectomy. A Cilt - Vol. 18 Sayı - No. 4

new trend for treatment of obstructing carcinoma of the left colon. Ann Surg 1989;210:220-3.

11. Arnaud JP, Bergamaschi R. Emergency subtotal/total colectomy with anastomosis for acutely obstructed carcinoma of the left colon. Dis Colon Rectum 1994;37:685-8.

12. Forloni B, Reduzzi R, Paludetti A, Colpani L, Cavallari G, Frosali D. Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction. Dis Colon Rectum 1998;41:23-7.

13. Day TK, Bates T. Obstructing/perforated carcinoma of the left colon treated by resection and the formation of a double colostomy. Br J Surg 1984;71:558-60.

14. Lamah M, Mathur P, McKeown B, Blake H, Swift RI. The use of rectosigmoid stents in the management of acute large bowel obstruction. J R Coll Surg Edinb 1998;43:318-21.

15. Wilson RG, Gollock JM. Obstructing carcinoma of the left colon managed by subtotal colectomy. J R Coll Surg Edinb 1989;34:25-6.

16. Deutsch AA, Zelikovski A, Sternberg A, Reiss R. Onestage subtotal colectomy with anastomosis for obstructing carcinoma of the left colon. Dis Colon Rectum 1983;26:22730.

17. Klatt GR, Martin WH, Gillespie JT. Subtotal colectomy with primary anastomosis without diversion in the treatment of obstructing carcinoma of the left colon. Am J Surg 1981;141:577-8.

18. Lee YM, Law WL, Chu KW, Poon RT. Emergency surgery for obstructing colorectal cancers: a comparison between rightsided and left-sided lesions. J Am Coll Surg 2001;192:71925.

19. Runkel NS, Hinz U, Lehnert T, Buhr HJ, Herfarth Ch. Improved outcome after emergency surgery for cancer of the large intestine. Br J Surg 1998;85:1260-5.

20. Chua CL. Surgical considerations in the Hartmann’s procedure. Aust N Z J Surg 1996;66:676-9.

21. Dudley HA, Racliffe AG, McGeehan D. Intraoperative irrigation of the colon to permit primary anastomosis. Br J Surg 1980;67:80-1.

22. Turan M, Ok E, Sen M, Koyuncu A, Aydin C, Erdem M, et al.

A simplified operative technique for single-staged resection of left-sided colon obstructions: report of a 9-year experience. Surg Today 2002;32:959-64.

23. Arnaud JP, Tuech JJ, Duplessis R, Pessaux P. et al. Role of subtotal/total colectomy in emergency treatment of occlusive cancer of the left colon. [Article in French] Ann Chir 1999;53:1019-22.

24. Torralba JA, Robles R, Parrilla P, Lujan JA, Liron R, Piñero A, et al. Subtotal colectomy vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma.

Dis Colon Rectum 1998;41:18-22.

25. Targownik LE, Spiegel BM, Sack J, Hines OJ, Dulai GS, Gralnek IM, et al. Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004;60:86574.

26. Hennekinne-Mucci S, Tuech JJ, Bréhant O, Lermite E, Bergamaschi R, Pessaux P, et al. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma.

Int J Colorectal Dis 2006;21:538-41.

27. Tan KK, Sim R. Surgery for obstructed colorectal malignancy in an Asian population: predictors of morbidity and comparison between left- and right-sided cancers. J Gastrointest 315

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Surg 2010;14:295-302.

28. Balogh A, Wittmann T, Varga L, Zöllei I, Lázár G, Baradnay G, et al. Subtotal colectomy for the treatment of obstructive left colon cancer. Follow-up results. [Article in Hungarian] Orv Hetil 2002;143:1577-83. [Abstract] 29. Arnaud JP, Cervi C, Duplessis R, Cattan F. [The role of sub-

316

total/total colectomy in the urgent treatment of obstructive cancer of the left colon]. [Article in French] J Chir (Paris) 1997;134:267-70. [Abstract] 30. Vuković M, Moljević N. Total colectomy-options in management of acute obstruction of the left-side colon. [Article in Serbian] Med Pregl 2008;61:43-7. [Abstract]

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):317-320

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.02223

Delici göz küresi yaralanmalarından sonra fitizis bulbi gelişiminde etkili olan faktörler The factors affecting the development of phthisis bulbi after penetrating eye injuries Mesut COŞKUN,1 Mustafa ATAŞ,2 Ali AKAL,2 Özgür İLHAN,1 Uğurcan KESKİN,1 Esra Ayhan TUZCU1

AMAÇ

BACKGROUND

Delici göz küresi yaralanmalarından sonra fitizis bulbi gelişimine etki eden faktörler araştırıldı.

We aimed to investigate the factors affecting the development of phthisis bulbi after penetrating eye injuries.

GEREÇ VE YÖNTEM

METHODS

2000-2006 yılları arasında delici göz küresi yaralanması nedeni ile tedavisi ve takipleri yapılan 132 hastanın kayıtları derlenerek, bunlar arasından fitizis bulbi gelişen 8 olgunun kayıtları geriye dönük olarak incelendi. Olgular, yaralanmanın tipi, niteliği, anatomik yeri, eşlik eden ön/arka segment patolojileri ve fitizis bulbi gelişimi yönünden incelendi.

The medical records of 132 patients admitted to our clinic between 2000-2006 with the diagnosis of penetrating eye injury were collected. The records of the eight patients who developed phthisis bulbi were evaluated retrospectively.

The aspects of anatomic localization, type of trauma, associated events, and development of phthisis bulbi were also investigated.

BULGULAR

RESULTS

Ortalama takip süreleri 2,06±1,47 (dağılım, 6 ay -5 yıl) olan 5 erkek, 3 kız toplam 8 fitizis bulbi gelişen olgunun yaş ortalaması 7,12±4,70 (dağılım, 2-16 yaş) idi. Fitizis bulbi olguların 3’ünde (%37,5) kapalı perforasyonu takiben gelişen endoftalmi nedeniyle, 3’ünde (%37,5) sklera gerisine uzanan zon 2-3 skleral perforasyon ve eşlik eden retina dekolmanı nedeniyle, 2 olguda (%25) da travmanın neden olduğu proliferatif vitreoretinopatiye bağlı gelişmişti. Ortalama fitizis bulbi gelişme süresi 5,5±2,13 (dağılım, 3-10 ay) idi.

The mean age of the eight patients (5 males, 3 females) was 7.12±4.70 years (range: 2-16 years) and the mean followup time was 2.06±1.47 years (range: 6 months–5 years).

Three of eight patients developed post-perforation endophthalmitis. Three patients had zone 2-3 scleral perforation and associated retinal detachment and the remaining two patients had proliferative vitreoretinopathy according to the trauma; all eight patients eventually developed phthisis bulbi. The mean time for the development of phthisis bulbi was 5.5±2.13 months (range: 3-10 months).

SONUÇ

CONCLUSION

Delici göz küresi yaralanmalarından sonra, görme prognozu ve fitizis bulbi gelişimini etkileyen en önemli faktörlerin yaralanmanın büyüklüğü ve anatomik yeri, eşlik eden ön ve arka segment patolojileri ile travmaya ikincil endoftalmi gelişimi olduğunu düşünmekteyiz.

After penetrating eye injuries, visual prognosis and development of phthisis bulbi were affected significantly by the factors including anatomic localization, size of the injury, associated anterior or posterior segment pathologies, and endophthalmitis secondary to the trauma.

Anahtar Sözcükler: Delici göz küresi yaralanması; endoftalmi; fitizis bulbi.

Key Words: Penetrating eye injury; endophthalmitis; phthisis bulbi.

Mustafa Kemal Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, Hatay; 2Kayseri Eğitim ve Araştırma Hastanesi, Göz Kliniği, Kayseri.

1 Department of Ophthalmology, Mustafa Kemal University Faculty of Medicine, Hatay; 2Department of Ophthalmology, Kayseri Training and Research Hospital, Kayseri, Turkey.

1

İletişim (Correspondence): Dr. Mesut Coşkun. Mustafa Kemal Üniversitesi Tıp Fakültesi Göz Hastalıkları ABD, Serinyol Kampüsü, Antakya, Turkey.

Tel: +90 - 326 - 229 10 00 e-posta (e-mail): drmesutcoskun@hotmail.com

317

Ulus Travma Acil Cerrahi Derg

Perforan göz yaralanmaları ciddi görme kaybı ve kalıcı göz küresi deformitelerinin en önemli sebeplerinden biridir. Çocuklarda kötü tasarlanmış ve standardı olmayan oyuncaklar, oyun amaçlı kullanılan patlayıcılar, kesici ve delici metal cisimler, erişkinlerde ise; iş ve trafik kazaları, özellikle kırsal kesimde yaşayanlarda organik, bitkisel ve hayvansal travmalar ile olmaktadır.[1-3] Delici göz küresi yaralanmalarıyla başvuran olgularda tedavinin amacı göz küresinin bütünlüğünü sağlamak, gözün görme kabiliyetini korumak ve oluşabilecek geç dönem komplikasyonlardan hastayı korumaktır.[4] Ülkemizde delici göz yaralanmaları ile ilgili birçok çalışma mevcut olup, bu çalışmalarda görme düzeyine etki eden faktörler ve epidemiyoloji üzerinde durulmuştur.[4-6] Fakat fitizis bulbi gelişimi neden olan prognostik faktörler ilgili bir çalışmaya rastlanmamıştır.

Bu çalışmada, perforan göz yaralanmalarından sonra fitiz bulbi gelişiminde öngördürücü klinik parametreleri belirlemeyi amaçladık.

GEREÇ VE YÖNTEM Bu çalışmada, 2000-2006 yılları arasında delici göz yaralanması ile kliniğimize başvuran ve cerrahi onarım uygulanan 132 olgunun dosya kayıtları geriye dönük incelendi. Bu incelemede dosya kayıtları düzenli olan ve yeterli izlem süresine sahip (en az 6 ay), gözünde fitizis bulbi gelişmiş 8 (%6) olgu çalışma kapsamına alındı.

Hasta dosyaları incelenirken, olgunun yaşı, cinsiyeti, travma öyküsü, ameliyat öncesi inceleme bulguları, başlangıç görme düzeyleri ve cerrahi girişimin özellikleri not edildi. Yaralanmanın niteliği, yara yeri yerleşimi ve travmanın tipi, “Oküler Travma Sınıflama Gurubunun” yapmış olduğu sınıflama kullanılarak belirlendi.[7] Bu sınıflamada yara yeri yerleşimi açısından göz küresi üç zona ayrılmıştır; korneal yaralanmalar zon 1, limbustan 5 mm posteriora kadar olan skleral yaralanmalar zon 2 ve skleranın anteriyorunundaki 5 mm’lik alanın gerisine uzanan yaralanmalar da zon 3 olarak tanımlanmıştır.

Ameliyat öncesi incelemede, yara yeri kirliliği, ön kameranın durumu ve hifema varlığı, lens hasarı, pupilla ve irisin durumu, uveal doku ve vitre prolapsusu ile arka segment bulguları incelendi. Ayrıca primer onarımdan sonra gelişen geç dönem komplikasyonlar, enfeksiyon ve uygulanan ikincil tedaviler not edildi.

BULGULAR Fitizis bulbi gelişen sekiz olgunun yaş ortalaması 7,12±4,70 (dağılım, 2 ile 16 yaş) arasında değişiyordu ve yaş ortalaması 7 idi. Olguların 3’ü kız, 5’i erkekti.

Hastalarımızın ortalama takip süresi 2,06±1,47 (dağı318

lım, 6 ay ile 5 yıl) arasında değişmekteydi (Tablo 1).

Yaralayıcı etken ve yara yerinin yerleşimine göre (oküler travma çalışma gurubunun ölçütleri temel alınarak) olgular incelendiğinde; olguların 3’ünde (%37,5) tek kullanımlık atık enjektör iğnesi ile meydana gelen kapalı perforasyon sonrasında gelişen endoftalmi nedeni ile fitizis bulbi gelişmişti. Üç olguda (%37,5) fitizis bulbi skleraya uzanan zon 2-3 yaralanma sonrasında gelişen retina dekolmanı ve arka segmen patolojilerine bağlı gelişti. Bu olgulara primer cerrahi onarım uygulanmış, fakat takiplerinde arka segment patolojileri ile ilgli ek bir girişim not edilmemişti. Olguların 2’sinde (%25) sklera gerisine uzanan zon 3 yaralanma ve üvea-vitreal doku prolapsusu vardı. Bu olgularda fitizis bulbi tablosu, primer onarımdan sonra gelişen proliferatif vitroretinopatiye ikincil olarak gelişmişti. Bu iki olguya primer onarımdan sonra ileri bir merkezde pars plana vitrektomi operasyonu uygulanmıştı.

Tüm bu olguların ilk başvuru sırasında görme düzeyleri, persepsiyon ile el hareketi arasında değişmekteydi. Travma sonrası fitizis bulbi gelişme süresi ortalama 5,5±2,13 (dağılım, 3-10 ay) ortalama 5,5 ay olarak saptandı (Tablo 1).

TARTIŞMA Delici göz küresi yaralanmaları sık görülmeleri, fiziki ve görsel sonuçlarının dramatik olmaları nedeni ile pek çok araştırmacı tarafından incelenmiştir. Bu çalışmalarda, görme düzeyi, travmanın tipi ve mekanizması, yara yerinin yerleşimi ve büyüklüğü, afferent pupilla defektinin varlığı, vitreus hemorajisi, lentiküler yaralanma, retina dekolmanı ve endoftalmi gelişimi önemli prognostik faktörler olarak gösterilmiştir.[7,8] Delici göz travması geçirmiş 132 olgunun kayıtlarını derlediğimiz çalışmamızda, bizim amacımız tüm olguların yaralanma nedenleri, yaranın büyüklüğü ve yerleşimi, eşlik eden herhangi bir enfeksiyon veya ek başka bir patolojinin varlığını araştıran epidemiyolojik bir çalışmadan ziyade, travmaya ikincil fitizis bulbi gelişmiş olan 8 olguyu ele alarak, araştırmamızı bu olguların kayıtlarından mevcut süreci hazırlayan etkenleri incelemekti. Dolayısı ile biz delici göz travmasının doğasını incelemekten ziyade fitizis gelişmiş olgularda bu sürece zemin hazırlayan muhtemel faktörler üzerinde durduk. Bu bakımdan çalışmamızda delici göz travması geçirmiş fakat fitizis bulbi gelişmemiş 124 hastanın verileri üzerinde ek bir değerlendirilme yapılmaması çalışmamızın kısıtlayıcı yönlerinden birisidir.

Yara yerinin büyüklüğü ve yerleşimi görsel prognozun önemli göstergelerinden biri olmasının yanı başında, geç dönemde fitizis bulbi gelişimine neden olan Temmuz - July 2012

Delici göz küresi yaralanmalarından sonra fitizis bulbi gelişiminde etkili olan faktörler

Tablo 1. Fitizis bulbi gelişen olguların yaşı, yara yeri yerleşimi, travmaya ikincil gelişen ek patolojiler, takip süreleri ve fitizis bulbi gelişme süreleri Yaş (yıl)

Yara yeri yerleşimi

Eşlik eden patoloji

2 4 4

Kornea-skleral (zon 2-3) Kornea (kapalı perforasyon) Kornea-skleral (zon 3)

5 7

Kornea (kapalı perforasyon) Kornea-skleral (zon 3)

8 11 16

Korneal (kapalı perforasyon) Kornea-skleral (zon 2-3) Limbo-skleral (zon 2-3)

Retina dekolmanı Endoftalmi Üvea-vitre prolapsusu, sekonder proliferatif vitreo-retinopati Endoftalmi Üvea-vitre prolapsusu, sekonder proliferatif vitreo-retinopati Endoftalmi Retina dekolmanı Retina dekolmanı

7.12±4.70*

Ortalama takip süresi

Fitizis bulbi gelişme süresi

6 ay 1.5 yıl 1 yıl

5 ay 10 ay 3 ay

2 yıl 1.5 yıl

4 ay 3.5 ay

3 yıl 2 yıl 5 yıl

5 ay 4 ay 4 ay

2.06±1.47*

5.5±2.13*

* Ortalama±standart sapma.

en önemli etkenlerden biridir.[4,9,10] Erbağcı ve arkadaşları[5] ekvatorun gerisine kadar uzanan zon 3 skleral yaralanmalı 6 olguda (toplam hastaların %4,5’i) fitizis bulbi geliştiğini bildirmişlerdir. Pelitli ve arkadaşları[4] delici göz küresi yaralanmalarından sonra fitizis bulbi gelişme oranını %20 (toplam 114 gözün 24’ünde) gibi çok daha yüksek oranlarda bildirmişlerdir. Hooi ve arkadaşları[10,11] kendi serilerinde perforan göz yaralanmalarından sonra fitizis bulbi gelişme oranını %11,5 olarak bildirmişlerdir. Bizim fitizis bulbi gelişen 8 olgumuzun (%6), 5’inde ekvatoru gerisine uzanan zon 2-3 skleral perforasyon vardı. Yaralanma skleranın gerisine uzandıkça prognoz kötüleşmekte, çünkü üveal doku, vitreus ve retinanın etkilenmesi göz bütünlüğünü sağlamayı zorlaştırmakta ve görme beklentisini zayıflatmaktadır.[11-13] Rahman ve arkadaşları[14] delici göz küresi yaralanmalarından sonra retina dekolmanı varlığının kötü prognoz göstergesi olduğunu ve gözün enükleasyona gitme riskini artırdığını belirtmişlerdir. Yine bir başka çalışma perforan göz yaralanmalarından sonra arka segmentte oluşan değişikliklerin görme beklentisini ciddi şekilde etkilediğini belirtmiş, travma sırasında ön kameranın tam kaybına neden olacak şiddetteki bir yaralanmanın oküler içeriğin önemli bir kısmının kaybına yol açarak, gözün bütünlüğü ve işlevi açısından kötü prognoz göstergesi olduğunu bildirilmiştir.[4] Bizim çalışmamızda fitizis bulbiye neden olan en önemli etken, ekvator gerisine uzanan skleral kesinin tetiklediği oküler içerik prolapsusu ve buna eşlik eden arka segment patolojileriydi. Fitizis bulbi gelişen 8 olgudan 3’ünde retina dekolmanı, 2’sinde proliferatif vitreoretinopati tespit edilmişti.

Delici göz yaralanmalarından sonra prognozu etkileyen önemli faktörlerden biride travma sonrası endoftalmi gelişimidir. Literatürde endoftalminin prognozu Cilt - Vol. 18 Sayı - No. 4

olumsuz yönde etkilediği, perforan göz yaralanmalarından sonra endoftalmi riskinin %2-7 arasında olduğu bildirilmiştir.[14,15] Pelitli ve arkadaşları[4] delici göz küresi yaralanmalarından sonra olguların %3,4’ünde endoftalmi geliştiğini bildirmiş, fakat endoftalmiye ikincil fitizis bulbi gelişimi ile ilgili herhangi bir bilgiye yer vermemişlerdir. Erbağcı ve arkadaşları[5] travma sonrası endoftalmi gelişen iki olgularının evisserasyona gittiğini bildirmişlerdir. Bizim çalışmamızda ise diğerlerinden biraz farklı olarak, tek kullanımlık enjektör iğnesinin neden olduğu kapalı perforasyonlu 3 olguda endoftalmi oluşmuş, uygulanan tüm tedavilere rağmen gözlerde fitizis bulbi gelişmişti. Her ne kadar bu olgularda geniş skleral yaralanmalar, üveal doku prolapsusu ve retina dekolmanı gibi dramatik tablolar olmasa da, endoftalmide fitizis bulbi gelişimi için ciddi bir potansiyele sahiptir.

Sonuç olarak, delici göz travması geçiren bir hastada fitizis bulbi gelişimi nispeten sık karşılaşılan bir durumdur. Bu süreçte etkili olan en önemli prognostik faktörlerin de, perforasyonun büyüklüğü ve anatomik yerleşimi, eşlik eden arka ve ön segment patolojileri, yaranın kirlenmesi ve endoftalmi gelişme riski olduğunu düşünmekteyiz.

KAYNAKLAR 1. McCormack P. Penetrating injury of the eye. Br J Ophthalmol 1999;83:1101-2.

2. Desai P, MacEwen CJ, Baines P, Minassian DC. Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome. Br J Ophthalmol 1996;80:592-6.

3. Dürük K, Budak K, Turaçlı E, Işık Çelik Y, Çekiç O. Delici göz yaralanmalarında prognostik faktörler. T Oft Gaz 1994;24:216-9.

4. Pelitli Gürlü V, Esgin H, Benian O, Erda S. The factors affecting visual outcome in open globe injuries. Ulus Travma Acil Cerrahi Derg 2007;13:294-9.

5. Erbağcı İ, Güngör K, Kaya Ü, Bekir NA. Perforan göz 319

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yaralanmalarının epidemiyolojisi, komplikasyonları ve görme prognozu. T Klin J Ophthalmol 2001;10:217-21.

6. Sarı A, Adıgüzel U, Dinç E, Argın A, Yılmaz A, Öz Ö ve ark. Çocukluk çağı delici göz yaralanmalarının epidemiyolojik değerlendirilmesi. T Oft Gaz 2008;38:504-8.

7. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, Bridges WZ Jr, Capone A Jr, Cardillo JA, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820-31.

8. Pieramici DJ, MacCumber MW, Humayun MU, Marsh MJ, de Juan E Jr. Open-globe injury. Update on types of injuries and visual results. Ophthalmology 1996;103:1798-803.

9. Pieramici DJ, Au Eong KG, Sternberg P Jr, Marsh MJ. The prognostic significance of a system for classifying mechanical injuries of the eye (globe) in open-globe injuries. J Trauma 2003;54:750-4.

10. Cruvinel Isaac DL, Ghanem VC, Nascimento MA, Torigoe

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M, Kara-José N. Prognostic factors in open globe injuries.

Ophthalmologica. 2003;217:431-5.

11. Hooi SH, Hooi ST. Open-globe injuries: the experience at Hospital Sultanah Aminah, Johor Bahru. Med J Malaysia 2003;58:405-12.

12. Thakker MM, Ray S. Vision-limiting complications in openglobe injuries. Can J Ophthalmol 2006;41:86-92.

13. Sobaci G, Mutlu FM, Bayer A, Karagül S, Yildirim E. Deadly weapon-related open-globe injuries: outcome assessment by the ocular trauma classification system. Am J Ophthalmol 2000;129:47-53.

14. Rahman I, Maino A, Devadason D, Leatherbarrow B. Open globe injuries: factors predictive of poor outcome. Eye (Lond) 2006;20:1336-41.

15. Brinton GS, Topping TM, Hyndiuk RA, Aaberg TM, Reeser FH, Abrams GW. Posttraumatic endophthalmitis. Arch Ophthalmol 1984;102:547-50.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):321-327

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.39000

Ocular trauma score in transferred fireworks-related ocular injuries: a case series Havai fişek taşımasında olan göz yaralanmalarında oküler travma skoru: Olgu serisi Yong LIU,1 Yi-Fei HUANG,2 Jing-Jing JIANG,2 Ji-Feng YU,2 Yu-Bo GONG,2 Xi-Bin ZHOU,2 Gai-Ping DU,2 Qian-Qian XU2 BACKGROUND

AMAÇ

Our aim was to review the characteristics of transferred fireworks-related ocular damage and to evaluate the prognostic value of the ocular trauma score (OTS) for these injuries.

Bu çalışmada amacımız, taşınan havai fişekle ilgili oküler hasar özelliklerini gözden geçirmek ve bu yaralanmalar için oküler travma skorunun (OTS) prognostik değerini araştırmaktır.

METHODS

GEREÇ VE YÖNTEM

This study included 22 transferred patients (19 male, 3 female; mean age 22.6±14.9 years) (25 eyes). The data were retrospectively reviewed, including the characteristics of the geography, types of fireworks, status of injuries, therapeutic procedures, and the best-corrected visual acuity (BCVA). All the injured eyes were classified using the OTS at the time of the initial examination.

Bu çalışmaya, 22 taşınan hasta (19 erkek, 3 kadın; ortalama yaş, 22.6±14.9 yaş) (25 göz) alındı. Coğrafya özellikleri, havai fişek tipleri, yaralanma durumu, terapötik prosedürler ve en iyi düzeltmiş görme keskinliği (BCVA) ile ilgili karakteristikleri içeren veriler geriye dönük değerlendirildi. Yaralanan bütün gözler, ilk inceleme sırasında OTS kullanılarak sınıflandırıldı.

RESULTS

BULGULAR

Twenty eyes (80%) were in OTS category 1, three eyes (12%) were in OTS category 2, and two eyes (8%) were in OTS category 3. All cases received surgical therapy. Six eyes (24%) were enucleated, four (16%) of which achieved an improvement in their final BCVA. There was a statistically significant improvement in final BCVA between OTS category 1 and the other two OTS categories (p=0.016).

Yirmi göz (%80) OTS kategori 1, üç göz (%12) OTS kategori 2 ve iki göz (%8) OTS kategori 3 olarak değerlendirildi. Bütün olgular cerrahi tedavi aldı. Altı göz (%24) enükle idi, bunların dördünde (%16) son BCVA’larında bir düzelme oldu. OTS kategori 1 ile diğer iki OTS kategorisi arasında son BCVA’da istatistiksel olarak anlamlı bir düzelme oldu (p=0,016).

CONCLUSION

SONUÇ

The aforementioned transferred fireworks-related ocular injury cases occurred mainly in young adults, men and active participants, all of which incurred serious vision loss and blindness. The OTS is quite effective for classifying the status and estimating the prognosis of transferred fireworks-related ocular injuries.

Taşınan havai fişek ile ilişkili oküler yaralanma olguları, esas olarak genç erişkinler, erkekler ile aktif katılımcılarda oluşmuş ve hepsi de ciddi görme kaybı ve körlüğe maruz kalmıştır. OTS, taşınan havai fişek ile ilişkili oküler yaralanmaların durumunun sınıflandırılmasında ve prognozunun tahmin edilmesinde oldukça etkindir.

Key Words: Fireworks; ocular injury; transfer; scores; prognosis; ocular trauma score (OTS).

Anahtar Sözcükler: Havai fişek; oküler yaralanma; taşınma; skorlar; prognoz; oküler travma skoru (OTS).

Department of Ophthalmology, Chinese Pla Air-force General Hospital, Beijing, China.

Çin Pla Hava Kuvvetleri Genel Hastanesi, Oftalmoloji Kliniği, Pekin, Çin.

Correspondence (İletişim): Yi-Fei Huang, M.D. Department of Ophthalmology, Chinese PLA General Hospital Beijing, China.

Tel: +86-10-66938123 e-mail (e-posta): 301yk@sina.com

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Fireworks are used during many celebrations internationally; however, they are dangerous if people do not give due attention to the necessary safety measures.

Injuries from fireworks remain a problem in several countries.[1-3] For example, fireworks were involved in an estimated 8,800 injuries in the United States (U.S.) hospital emergency departments in 2009 (95% confidence interval of 6,800 to 10,800).[1] The U.S. Consumer Product Safety Commission (CPSC; Bethesda, MD, USA) staff estimated that there were 7,000 fireworks-related injuries during 2008.[1] The CPSC also estimated that 92% of the victims of fireworks-related injuries were treated in the emergency department and then released. In 2009, approximately 2% of the victims were treated and transferred to another hospital, and slightly more than 5% were admitted to the hospital.[1] Ocular damage/harm was one of the most common fireworks-related injuries.[2-4] Setting off fireworks is also a tradition during the Spring Festival in China, which symbolizes the coming of the Chinese lunar new year, and as a result, many ocular injuries are sustained during this period.[5] As a tertiary referral hospital and the largest military hospital in China, the Chinese PLA General Hospital treated mainly transferred, fireworks-related ocular injury patients. To review the characteristics of these transferred ocular injuries and the results of treatments, this retrospective study concentrated on 22 patients (25 eyes) who were transferred to the Chinese PLA General Hospital during the period of the previously mentioned Spring Festivals from 2006 to 2010. This study was approved by the Ethical Board Committee of the Chinese PLA General Hospital.

Fireworks-related ocular injuries included in the study covered a wide spectrum of ocular trauma in terms of anatomical involvement, such as superficial and deep injuries (i.e., ranging from the eyelids to the optic nerve); the type of injury, for instance, penetration, contusion, rupture, and intraocular foreign body (IOFB); as well as the mechanism of injury, including, but not limited to, blunt, penetrating, and/or thermal wounds.[6,7] At the time of this study, there were no specialized scoring systems available for classifying fireworks-related ocular injuries. To obtain a quantifying analysis on the status of these transferred ocular injuries, the study classified these injuries by means of the ocular trauma score (OTS). The OTS was published in 2002 and can provide good estimations of the prognosis of ocular trauma. This system was mainly used to classify the mechanical injuries of the eye. It describes the anatomic and functional status of the eye following trauma. Its purpose is to standardize the diagnosis, and it serves to identify characteristics associated with greater severity of the initial eye condition.

According to the score obtained from this scale, the injured eye can be placed into one of five categories, 322

each of which has a distinct probability of reaching a range of visual function.[8,9] Though many studies have focused on characteristics of fireworks-related ocular injuries, the quantitative analysis on the type of trauma was insufficient. Therefore, our aim was to prospectively analyze these transferred fireworksrelated ocular injuries by means of the OTS. The OTS results will help us quantitatively evaluate the characteristics of ocular fireworks injuries and to evaluate the prognostic value of OTS for these injuries.

MATERIALS AND METHODS For this study, we performed an observational, retrospective study on patients who were transferred from community hospitals into the Ophthalmology Department of the Chinese PLA General Hospital. Medical histories were obtained via the medical records of all patients. All transferred patients with fireworks-related ocular injuries between January 2006 and March 2010 were included, and we extracted demographic information, types of fireworks used most often and which type frequently resulted in eye injury, sites and severities of the injuries, and the diagnosis and management of each, as well as the patientsâ&#x20AC;&#x2122; condition at the time of discharge and the last follow-up examination.

All patients were examined by slit-lamp biomicroscopy, ophthalmotonometer, gonioscopy, direct and indirect ophthalmoscopy, and type B ultrasonic scan, in the event that the posterior segment status, such as retinal detachment (RD) or vitreous hemorrhage, was not well-visualized. Furthermore, computerized tomography (CT) scan was performed if needed to rule out IOFB. For this study, we used the OTS to classify patients at their initial examination in our hospital. This classification system distinguished between closed- (CG) and open- globe (OG) trauma. The aforementioned trauma was classified as A, B, C and D when the globe was closed: A, contusion; B, lamellar laceration; C, superficial foreign body; and D, mixed. In OG trauma, type A was labeled as rupture; type B as penetration; type C as IOFB; type D as perforation (2 continuity solutions for the same sharp agent); and type E as mixed type. Vision grade (best-corrected visual acuity [BCVA] in the injured eye and Snellen equivalents) was classified as follows: (1) â&#x2030;Ľ20/40; (2) 20/50 to 20/100; (3) 19/100 to 5/200; (4) 200 to light perception; and (5) No light perception. The pupil was scored as positive or negative according to the presence or absence of an afferent pupillary defect, respectively.

Three zones of injuries were defined by the location of the most posterior full-thickness aspect of the globe.

The final score was obtained through the score of the initial BCVA, from which were subtracted the scores of the other characteristics (Table 1). With the final Temmuz - July 2012

Ocular trauma score in transferred fireworks-related ocular injuries

ences (SPSS) version 15.0 (SPSS, Inc., Chicago, IL, USA) was used for all statistical analyses. Significance was set at p<0.05. Fisherâ&#x20AC;&#x2122;s exact test was used as appropriate.

Table 1. Calculating the ocular trauma score (OTS) variables and raw points in the OTS study Variables

Raw points

Initial vision NLP LP/HM 1/200 to 19/200 20/200 to 20/50 20/40 Rupture Endophthalmitis Perforating injury Retinal detachment Afferent pupillary defect

RESULTS A total of 22 patients (25 eyes) with fireworks-related ocular injuries were collected. The demographic information is shown in Table 2.

60 70 80 90 100 23 17 14 11 10

Twenty-two eyes (88%) had OG trauma: nine eyes (36%) had type A; two eyes had type B (8%); four eyes had type C (16%); three eyes had type D (12%); and four eyes had type E (16%). Three eyes (12%) presented with CG trauma corresponding to type A in two eyes (8%) and type B in one eye (4%). Nineteen eyes (76%) presented afferent pupillary defect. All of the injured eyes corresponded with zone III. A total

HM: Hand movements; LP: Light perception; NLP: No light perception.

Table 2. Demographic information (n=22) Variable

n

Age (years) <10 10 to 18 19 to 44 45 to 59 >60 Sex Male Female Circumstance Participant Bystander Residence Rural Urban

4 7 9 2 0

19 3

16 6

15 7

Table 4. Injury patterns (n=25)

% 18 32 41 9 0 86 14 73 27 68 32

score, each eye evaluated was placed within an OTS category: category 1: 0 to 44 points, category 2: 45 to 65 points, category 3: 66 to 80 points, category 4: 81 to 91 points, and category 5: 92 to 100 points.[8,9] Statistical Analysis Follow-up examination was performed 8 to 24 months after all patients were discharged from the hospital. The Statistical Package for the Social Sci-

Location of firework-related ocular injuries

n

%

Anterior segments Hyphema Cornea/corneosclera laceration Iris laceration/dialysis Cataract Cyclodialysis Subluxation/luxation of lens Posterior segment Vitreous hemorrhage Retinal detachment Choroidal detachment Extrusion of intraocular content Epichoroidal space hemorrhage Retinal impaction Posterior scleral rupture IOFB Appendages of the eye Eyelid laceration Blowout fracture Burns Eyelid Ocular surface

19 17 15 11 6 5

76 68 60 44 24 20

23 21 17 15 11 9 7 4

92 84 68 60 44 36 28 16

20 9

9 7

80 36 36 28

IOFB: Intraocular foreign body.

Table 3. The types of fireworks-related ocular injuries Type

Number of cases (n=22)

Number of eyes (n=25)

n

%

n

%

Aerial firework shells Firecrackers Bottle rockets Homemade fireworks Gravel buried with fireworks Unknown

9 6 3 2 1 1

41 27 14 9 5 5

10 6 5 2 1 1

40 28 20 8 4 4

Cilt - Vol. 18 SayÄą - No. 4

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of 20 eyes (80%) were classified as OTS category 1, three eyes (12%) as OTS category 2, and two eyes (8%) as OTS category 3.

The types of fireworks-related ocular injuries are summarized in Table 3. The highest proportion of cases (41%) were injured by shells of aerial fireworks.

This type of firework is not closely related with the category of OTS in this study (Fisherâ&#x20AC;&#x2122;s exact test p>0.05): eight of 20 eyes in OTS category 1 were injured by aerial shells, while two of five eyes in OTS categories 2 and 3 were injured by the same type of fireworks.

Table 4 shows the detailed injury patterns. The most common anterior segment injuries were anterior chamber hyphema (Fig. 1a, b). Others included cor-

nea/corneosclera laceration (Fig. 1a), iris laceration/ dialysis (Fig. 1b, e), cyclodialysis (Fig. 1f), and cataracts and subluxation/luxation of lens (Fig. 1a, b). The most posterior segment injuries were vitreous hemorrhage (Fig. 1c). Other injuries included RD (Fig. 1d), extrusion of intraocular content, choroidal detachment (Fig. 1d), and epichoroidal space hemorrhage, etc.

The injuries of appendages of the eye were common.

Twenty eyes (80%) had eyelid laceration and nine eyes (36%) had blowout fractures. Nine eyes (36%) suffered first- and second-degree eyelid burns according to the classification of thermal eyelid burns.[10] Seven eyes (28%) had ocular surface burns of grades 1 and 2 of the Roper-Hall classification system.[11] Ten patients (45%) suffered a combination of first- and second-degree burns of the head, face, extremities, and trunk.

(a)

(b)

(c)

(d)

(e)

(f)

Fig. 1. Corneal open globe injury, corneal foreign bodies, and traumatic cataract are shown (a). The anterior chamber hyphema and iridodialysis (b) were shown by slit-lamp biomicroscopy examination. Vitreous hemorrhage was observed by ophthalmoscopy examination (c). Retinal and choroidal detachment was shown by B-type ultrasound scan (d). Iris laceration/dialysis (e) and cyclodialysis (f) were observed by ultrasound biomicroscopy.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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Ocular trauma score in transferred fireworks-related ocular injuries

Table 5. BCVA at presentation and final examination BCVA

At presentation

Final

Number of eyes (n=25)

Number of eyes (n=19)

≥20/40 20/200 to 20/50 1/200 to 19/200 LP to HM NLP

1 2 1 13 8

4.0 8.0 4.0 52.0 32.0

2 2 3 11 1

10.5 10.5 15.8 57.9 5.3

Note: At presentation, n=25 eyes; final, n=19 eyes (6 eyes were enucleated during the follow-up).

BCVA: Best-corrected vision acuity. HM: Hand movement; LP: Light perception; NLP: No light perception.

The BCVA on presentation and at the final followup examination are summarized in Table 5. Furthermore, only one of 20 eyes in OTS category 1 achieved an improvement in final BCVA of more than one grade of vision, although three of five eyes in OTS categories 2 and 3 achieved an improvement in their final BCVA more than one grade of vision. Fisher’s exact test showed a statistically significant improvement in final BCVA between the OTS category 1 and the other two OTS categories (p=0.016).

Table 6 shows surgical management. A total of 21 eyes (84%) received pars plana vitrectomy and fluid/ gas exchange. Twenty eyes (80%) received silicon oil tamponade. Eighteen eyes (72%) received relaxing retinotomy/retinal proliferative membrane peeling for retinal incarceration and proliferative disease.

Other treatments included anterior chamber washout, removal of epichoroidal space hemorrhage, and lensectomy, etc. Six eyes (24%) were enucleated in the study: three eyes were enucleated because the scleral ruptures were up to the roots of the optic nerves and most of intraocular contents were lost during the onestage operation, and the other three eyes were enucleTable 6. Surgical management of ocular injuries (n=25) Management

n

%

Pars plana vitrectomy/gas-fluid exchange Retinal laser therapy Silicon oil tamponade Relaxing retinotomy/ Retinal proliferative membrane peel Anterior chamber washout Removal of epichoroidal space hemorrhage Pars plana lensectomy Removal of silicon oil Enucleation Extraction of IOFB Phacoemulsification and PCIOL Iris repair/reconstruction C3F8 tamponade

21 21 20

84 84 80

18 13 11 11 9 6 4 3 3 1

72 52 44 44 36 24 16 12 12 4

PCIOL: Posterior chamber intraocular lens; IOFB: Intraocular foreign body.

Note: Eleven eyes had more than two surgeries including removal of silicon oil, PCIOL implantation, enucleation, etc.

Cilt - Vol. 18 Sayı - No. 4

ated for severe eyeball atrophy during the follow-up examination. All of the enucleated eyes were classified as OTS category 1. None of the injured eyes was diagnosed as endophthalmitis.

DISCUSSION Many studies have reported about fireworksrelated ocular injuries during ceremonies in different countries.[1-7,12,13] Kuhn et al.[14] found that 61% of serious fireworks-related cases with at least six months of follow-up therapy had a final visual acuity worse than 20/40. In order to review the results of transferred fireworks-related ocular injuries, the authors collected 22 patients (25 eyes) that were injured by fireworks during the Spring Festival in China. All patients were transferred to our hospital in order to obtain more professional ocular care.

Fifty percent of these cases were children and juveniles (<18 years old). This consequence is consistent with the results of previous studies, which reported that 41.7%[5] and 69%[15] of fireworks-related injuries occurred in the same age group. However, for the respective group of this study, the young adults (19-44 years old) were injured more by the fireworks than other groups. The reason for this may be that young adults would more likely ignite large fireworks and firecrackers than any other age group. In this study, the main types of the fireworks-related injuries were from aerial shells and firecrackers. However, the type of firework does not closely correlate with the category of OTS in this study (Fisher’s exact test p>0.05).

Therefore, we conclude that the status and prognosis of the transferred ocular injuries are not connected to the type of firework involved.

Sixty-eight percent of the patients lived in rural areas. The result coincides with a previous study.[5] One reason may be that people who live in rural areas are more apt to use lower-quality products. The gender difference of the study is in line with the results of previous studies, all of which had reported males as the high-risk group for such injuries.[1,5,7,12-17] Sixteen (73%) of patients were the active participants while six patients (27%) were bystanders, which is not con325

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sistent with previous studies.[7,14,17] We conclude that active participants are more easily injured than bystanders.

Many publications that focused on fireworks-related ocular injuries explored the clinical aspects of the problem or the impact of legislation on the injuries.

[2,4,5,13,15,17] Our study focused on the characteristics and prognosis of the transferred fireworks-related ocular injuries. In order to achieve a quantitative analysis, the study used the OTS to evaluate injuries. The advantages of this study are the quantitative evaluation and analysis. The disadvantage of the study is that the included cases do not represent a large sample. From the OTS results, we found that all of the transferred cases in the study incurred severe ocular injuries: 80% of the injured eyes were evaluated as OTS category 1, while the other injured eyes were OTS categories 2 and 3. In addition, we found that the prognosis of injured eyes in OTS category 1 was poorer than that of eyes in the other two OTS categories: there was a statistically significant improvement in final BCVA between OTS category 1 and the other two OTS categories (Fisher’s exact test p=0.016). None of the eyes in OTS category 1 achieved an improvement in final BCVA of 20/100 or better. All injured eyes that achieved BCVA equal to or better than 20/100 were in OTS categories 2 and 3.

Furthermore, six eyes that were enucleated at the first admission and at the end of the follow-up period were in OTS category 1.

Although the transferred cases had a combination of burn injuries that were non-mechanical injuries, the degree of the ocular burns was less than second grade according to Roper-Hall’s classification system. The damage due to the ocular burns did not affect the patients’ final vision or ocular integrity.

Although 20 eyes (80%) had OG injuries, none of the injured eyes was diagnosed as endophthalmitis in this study. This result is not consistent with previous studies, which have reported that morbidity of endophthalmitis ranged from 1% to 12%.[5,15,18] It is possible that all of the patients received timely microsurgical surgeries and anti-infection drugs; however, perhaps the sample size was too small.

Although new microsurgical techniques, such as vitrectomy, retinal laser, silicone oil, etc., are used to treat these types of injuries, the outcomes of the patients transferred with ocular injuries are not satisfactory. We need to take measures to avoid these severe fireworks-related ocular injuries. The making, selling and setting off of fireworks should be done under proper supervision to reduce and/or prevent the occurrence of severe ocular injuries.

In conclusion, we find that all transferred fireworks-related ocular injuries are severe injuries ac326

cording to OTS. The injuries occur mainly in young adults, men, and active participants, all of which result in serious vision loss and blindness. The OTS is effective for evaluating the status and estimating the prognosis of transferred fireworks-related ocular injuries.

The OTS results can be useful for guiding treatment and counseling patients during the initial examination in the hospital. The ocular injuries in OTS category 1 have poorer prognosis on final BCVA and on anatomical integrity of the eye than observed in the other OTS categories.

REFERENCES 1. Michael A, Greene, Yongling Tu. 2009 Fireworks Annual Report: fireworks-related deaths, emergency department treated injuries, and enforcement activities during 2009.

Washington, DC: US Consumer Product Safety Commission; 2009.

2. Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworksrelated injuries in the United States: 1990-2003. Pediatrics 2006;118:296-303.

3. Knox FA, Chan WC, Jackson AJ, Foot B, Sharkey JA, McGinnity FG. A British Ophthalmological Surveillance Unit study on serious ocular injuries from fireworks in the UK. Eye (Lond) 2008;22:944-7.

4. Vassilia K, Eleni P, Dimitrios T. Firework-related childhood injuries in Greece: a national problem. Burns 2004;30:151-3.

5. Jing Y, Yi-qiao X, Yan-ning Y, Ming A, An-huai Y, Lian-hong Z. Clinical analysis of firework-related ocular injuries during Spring Festival 2009. Graefes Arch Clin Exp Ophthalmol 2010;248:333-8.

6. Mohammadi SF, Mohammadi SM, Ashrafi E, Hatef E, Rahbari H. Editorial: Chaharshanbe-Soori Fireworks and Public Health. Iranian Journal of Ophthalmology 2011;23:1-2.

7. Mansouri MR, Mohammadi SF, Hatef E, Rahbari H, Khazanehdari MS, Zandi P, et al. The Persian Wednesday Eve Festival “Charshanbe-Soori” fireworks eye injuries: a case series. Ophthalmic Epidemiol 2007;14:17-24.

8. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am 2002;15:163-5.

9. Lima-Gómez V, Blanco-Hernández DM, Rojas-Dosal JA. Ocular trauma score at the initial evaluation of ocular trauma.

Cir Cir 2010;78:209-13.

10. Malhotra R, Sheikh I, Dheansa B. The management of eyelid burns. Surv Ophthalmol 2009;54:356-71.

11. Roper-Hall MJ. Thermal and chemical burns. Trans Ophthalmol Soc U K 1965;85:631-53.

12. Tavakoli H, Khashayar P, Amoli HA, Esfandiari K, Ashegh H, Rezaii J, et al. Firework-related injuries in Tehran’s Persian Wednesday Eve Festival (Chaharshanbe Soori). J Emerg Med 2011;40:340-5.

13. Sundelin K, Norrsell K. Eye injuries from fireworks in Western Sweden. Acta Ophthalmol Scand 2000;78:61-4.

14. Kuhn FC, Morris RC, Witherspoon DC, Mann L, Mester V, Módis L, et al. Serious fireworks-related eye injuries. Ophthalmic Epidemiol 2000;7:139-48.

15. Singh DV, Sharma YR, Azad RV. Visual outcome after fireworks injuries. J Trauma 2005;59:109-11.

16. Levitz LM, Miller JK, Uwe M, Drüsedau H. Ocular injuries caused by fireworks. J AAPOS 1999;3:317-8.

Temmuz - July 2012

Ocular trauma score in transferred fireworks-related ocular injuries

17. Rashid RA, Heidary F, Hussein A, Hitam WH, Rashid RA, Ghani ZA, et al. Ocular burns and related injuries due to fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia. Burns 2011;37:170-3.

Cilt - Vol. 18 Say覺 - No. 4

18. Mansouri M, Faghihi H, Hajizadeh F, Rasoulinejad SA, Rajabi MT, Tabatabaey A, et al. Epidemiology of open-globe injuries in Iran: analysis of 2,340 cases in 5 years (report no.

1). Retina 2009;29:1141-9.

327

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):328-332

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.82084

Are we prepared for orthopedic trauma surgery outside normal working hours? A retrospective analysis Normal çalışma saatleri dışında ortopedik travma cerrahisi için hazır mıyız?

Retrospektif bir analiz Mansour A Al-SAFLAN, Mohammed Q AZAM, Mir SADAT-ALI

BACKGROUND

AMAÇ

This retrospective analysis was done to determine whether there is a change in outcomes of trauma patients undergoing intramedullary nailing (IMN) for femur and tibia fracture as an emergency versus elective procedure.

Bu geriye dönük çalışma, femur ve tibia kırığına bağlı intramedüller çivileme (İMÇ) işlemi geçiren hastalarda elektif prosedüre karşı acil girişim sonuçlarında bir değişiklik olup olmadığını belirlemek amacıyla yapıldı.

METHODS

GEREÇ VE YÖNTEM

Data were collected for all patients admitted to male orthopedic wards between 1 January 2004 and 30 June 2009 with femur and tibia fractures that required IMN. The data collected included surgery undertaken on as emergency or elective procedure, duration of surgery, complications encountered, and union status of fracture.

Tüm veriler, 1 Ocak 2004 ile 30 Haziran 2009 tarihleri arasında İMÇ gerektiren femur ve tibia kırığı olan erkek hastaların kaldığı ortopedi yatakhanelerinden toplandı. Toplanan veri, acil veya elektif prosedür şeklinde gerçekleştirilen cerrahiyi, cerrahinin süresini, karşılaşılan komplikasyonları ve kırığın kaynama durumunu içerdi.

RESULTS

BULGULAR

There were 431 fractures of the tibia, fibula and femur.

Operating time for femur fracture as an emergency procedure was significantly greater than for elective surgery (191±79 versus 155±65 minutes; p≤0.001, confidence interval [CI] -19.54). For tibia fracture, operating times were 167.1±62 versus 69.2±35 minutes (p<0.001, CI <-85.4). Complications of infection, secondary surgery and of union were more common in emergency procedures than elective surgeries.

Tibia, fibula ve femur 431 kırık vardı. Femur kırığı ile ilgili ameliyat süresi, acil bir prosedür şeklinde gerçekleştirilmesi durumunda elektif prosedür olarak gerçekleştirilme durumuna göre anlamlı şekilde daha uzundu (191±79 ve 155±65 dk; p≤0.001, güven aralığı [GA] -19.54). Tibia kırığında ameliyat süresi 167.1±62 ve 69.2±35 dk bulundu (p<0.001, GA <-85.4). Enfeksiyon, ikincil cerrahi ve kaynama komplikasyonları, elektif cerrahiye göre acil prosedürlerde daha yaygındı.

CONCLUSION

SONUÇ

This study shows that complications are higher in emergency surgery than elective surgery due to the increase in the duration of surgery. This is attributed to the non-availability of dedicated trained orthopedic nursing staff and theater during emergency procedures. We believe that it is time to develop dedicated orthopedic trauma theaters in hospitals that treat emergency fracture fixations.

Cerrahi süresindeki artış nedeniyle acil cerrahide komplikasyonlar elektif cerrahiye göre daha yüksek bulunmuştur.

Bu durum, acil prosedürler sırasında özel eğitimli ortopedik hasta bakım personeli ve ameliyathanenin bulunmamasına bağlanabilir. Hastanelerde acil kırık tespitleri ve tedavisi icin özel ortopedi travma alanları oluşturulması gerektiğine inanmaktayız.

Key Words: Emergency care; elective surgery; fractures; trauma.

Anahtar Sözcükler: Acil bakım; elektif cerrahi; kırıklar; travma.

College of Medicine, University of Dammam, King Fahd Hospital of the University, Alkhobar, Saudi Arabia.

Damman Üniversitesi, Tıp Fakültesi, Kral Fahd Üniversite Hastanesi, Alkhobar, Suudi Arabistan.

Correspondence (İletişim): Mir Sadat-Ali, M.D. Po Box 40071, King Fahd University Hospital, 31952 AlKhobar, Saudi Arabia.

Tel: +966 - 505848281 e-mail (e-posta): drsadat@hotmail.com

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Are we prepared for orthopedic trauma surgery outside normal working hours?

Trauma is the major cause of morbidity and mortality in the world and is a major cause of economic burden. In the United States in 2000 alone, the 50 million injuries required treatment costing $406 billion, and males accounted for approximately 70% ($283 billion) of the total costs of injuries.[1] During the same year in the United Kingdom, the cost of hip fractures alone were reported at an estimated £726 million.[2] The basic epidemiological data on the incidence of fractures due to trauma and their distribution in the population in Saudi Arabia is non-existent,[3] even though studies of road traffic accidents in the country are well-reported.[4-8] The immediate and definitive operative care of all fractures represents the optimal treatment for the patient, and this early total approach has been shown to be beneficial in comparison to elective surgery.[9-11] Challenges that are unique to the orthopedic specialty are the availability of an operating room to perform trauma surgery, and secondly, of specialized orthopedic nursing staff outside normal working hours, which improves productivity and the satisfaction of orthopedic surgeons as well as the patient outcomes.[12] At our institution, a tertiary care trauma center, a dedicated orthopedic and trauma operating room and trained staff are not available outside normal working hours. Hence, fractures lose priority over blunt abdominal trauma, head injury and obstetrical emergencies. Orthopedic cases are done at the end of the day or at odd hours at night or even weekends with inexperienced supporting staff. Fortunately, only a small percentage of these injuries constitute surgical emergencies (compound fracture, pelvic injuries, fractures with neurovascular compromise, etc.). The majority of the cases fall under the subgroup “urgent” rather than “emergent”, which should be done within 24 hours, but not necessarily at midnight.[13] Various studies undertaken recently showed that night-time surgeries increase various complication rates. Realizing these ominous challenges, new trends have been emerging recently to develop a dedicated orthopedic trauma staff and theaters.

The purpose of this study was to compare complications of intramedullary nailing (IMN) done for fractures of the femur and tibia as an emergency (without dedicated orthopedic operating room and trained orthopedic staff) versus elective procedure. We hypothesized that surgeries performed without significant back-up from paramedical trained staff result in increased mortality and morbidity.

MATERIALS AND METHODS After obtaining approval from the Ethical and Research Committee of the College of Medicine, University of Dammam, and King Fahd Hospital of the Cilt - Vol. 18 Sayı - No. 4

University Al-Khobar, data were collected for all male patients with fractures and dislocations admitted to the hospital between 1 January 2004 and 30 June 2009 through computer-based ICD codes using the UltiCare system. The inclusion criteria were fractures of the femur and tibia in patients ≥12 years of age treated by IMN, who were admitted after the trauma. All pathological fractures were excluded. The fracture patterns were classified according to the Orthopedic Trauma Association system,[14] and open fractures were graded using the Gustilo system.[15] The medical records were reviewed, and data gathered included the mechanism of injury, age, fracture level, the mechanism of injury (classified as due to road traffic accidents, motorcycle accidents, fall from a height, sports-related and miscellaneous, e.g. crushing injury and assault), associated injuries, and complications. The data were cross-referenced against data recorded in the ward admission log books and operating room registers for completeness and accuracy.

The time of injury, time of surgical intervention and delay in surgical fixation were meticulously documented. Type of anesthesia, duration of surgery, blood loss, and per-op transfusion were also recorded. Early or late postoperative complications and any revision needed were documented. Evaluations of treatment failure were done in terms of need for secondary operative treatment, salvage internal fixation, infection, and delayed, mal or non-union. Data were entered in the database and analyzed. Two-tailed non-paired Student’s t-test was used to compare means between patients who were operated under emergency versus elective conditions. Analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 14.0 (Chicago, IL, USA). A p value of <0.05 with 95% confidence interval (CI) was used to indicate statistical significance.

RESULTS There were 431 fractures of the tibia, fibula and femur. Table 1 shows the demographic data of the patients and causes of fractures. The majority of the patients were in the younger age group of less than 40 years. The age-specific incidence showed a bi-modal age distribution, with one peak in the second decade and a second major peak in the fourth decade. Two hundred and forty-eight (57.5%) of the injuries were sustained due to road traffic accidents. Out of 431 patients, 109 (25.3%) had associated injuries to the head (29) and chest (47) and blunt trauma to the abdomen (63). These commonly included subdural hematoma, brain contusion, rib fractures, lung contusion, liver laceration, and splenic injuries. Three cases had cervical injury (not requiring fixation) and one patient had thoracic aorta rupture, which was operated on an 329

Ulus Travma Acil Cerrahi Derg

Table 1. Demographic data and causes of fractures Age (years) mean: 28.9±14.6 <40 years: 326 >40 years: 105 Mechanism of injury Motor vehicle accidents Motorcycle Pedestrian Fall at home Sports Fall from height Industrial Gunshot Fireworks

Number of patients 192 56 65 25 46 37 9 7 3

emergency basis; the femur in this patient was fixed after two days as an elective procedure.

One hundred and ninety-five patients sustained femoral fractures, whereas 236 were tibial fractures.

There were 196 compound fractures (Gustillo I=98, Gustillo II=60 and Type III=38). Two hundred and seventeen (50.3%) were operated as elective procedure and the rest as emergency procedures. Table 2 shows the details of the 195 femoral fractures, of which 105 (53.8%) were operated as elective and 90 (46.2%) as emergency procedures. Operating time for femur fracture as an emergency procedure was significantly greater than in the elective group (191±79

versus 155±65 minutes; p≤0.001, CI -19.54) and the number of overall complications observed in elective procedures was 23 compared to 54 in the emergency group. For femur fracture, recon intramedullary nails were used in 17 patients (12 elective, 5 emergency).

Distal femoral nail was used in three elective cases and two emergency surgeries. In the remaining 173 patients, antegrade interlocked femoral nail was used.

All intramedullary femoral nailing was reamed and cannulated. All nails for the tibia were unreamed solid nails (A.O.).

There were 236 tibial fractures; 111 (47%) were operated as an elective procedure and 125 (53%) as emergency. The duration of surgery was significantly higher in the emergency procedures when compared to the elective nailings (167.1±62 versus 69.2±35 minutes; p<0.001, CI <-85.4). Complications in the emergency procedures were significantly higher, at 63, versus 30 in the elective group (Table 3).

DISCUSSION Femoral fractures occur in about 37.1 per 100,000 person-years in the United States, may be life-threatening and may be the cause of permanent disability if the treatment is delayed. IMN is the preferred method for treating such fractures. In general, IMN results in high union and low complication rates.[16] Many factors influence the results of IMN, and our study showed increased complications when IMN was done as an emergency procedure without the availability of

Table 2. Details of femoral IMN done as elective versus emergency procedure

Femur fracture (n=195)

Elective

Emergency

p

CI

Number of patients Duration of surgery (mins) Infection Fat embolism Secondary surgery Non-union

105 155±65 5 3 11 4

90 191±79 14 2 29 9

0.001 0.01 0.9 0.001 0.05

<-19.54 <0.016 <0.702 <-0.0607 <0.050

IMN: Intramedullary nailing; CI: Confidence interval.

Table 3. Details of tibial IMN done as elective versus emergency procedure

Tibia fracture (n=236)

Elective

Emergency

p

CI

Number of patients Duration of surgery (mins) Infection Fat embolism Secondary surgery Non-union

111 69.2±35 6 7 11 6

125 167.11±62 18 4 27 14

<0.001 <0.001 <0.24 <0.001 <0.008

<-85.4 <-7.35 <7.993 <9.88 <-3.351

IMN: Intramedullary nailing; CI: Confidence interval.

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Are we prepared for orthopedic trauma surgery outside normal working hours?

a specially trained nursing staff.

We observed a statistically significant increase in the duration of surgeries, blood loss, wound complications, infections, revision surgeries, and delayed unions. Technical errors like prominence of nail or locking bolts causing early removal of implants were seen more commonly in patients operated at night.

Delayed and non-union after IMN of the femur is reported to be less than 10%,[17,18] and in tibial fractures, the incidence was 8-16%.[19] In this study, the incidence of non-union in femur fractures was 5.69% and in tibia fractures was 8.47%, but the incidence was significantly higher in patients who underwent surgery as an emergency procedure at night as compared to a daytime surgery.

We believe that the increase in complications in emergency nailings was due to the following factors an inexperienced operating room staff, which includes the scrub nurse, circulating staff and the image technician, and an unforeseen need for specialized instruments/ inventory. Our results are similar to Bhattacharya et al.[20] for closed femoral nailings done at night. A literature review[21-24] shows that operating during the daytime decreases morbidity, and our results concur with the cited reports. Bhattacharya et al.[20] observed that inexperienced operating room personnel contributed significantly to the increased surgical time required in cases operated after 5 p.m. Ricci et al.[18] stated that daytime orthopedic surgeries have the potential to reduce minor complication rates for intramedullary nail fixation. Elder et al.[22] in a retrospective analysis found statistically significant improvement in surgical outcome when IMN was performed in dedicated orthopedic trauma centers. Lemos et al.[13] remarked that operating in the daytime decreases morbidity, and further added that part of this effect may be related to a more optimal nutrition and hydration status. To reduce complications in elderly patients, Zagrodnick and Kaufner[25] suggested that it is advisable to operate as an elective rather than emergency procedure in femoral fractures so that proper assessment can be made.

It was reported earlier that in fixation of fractures as an emergency procedure versus before 72 hours, there was no difference in complications between the two groups.[26] Among the systemic complications seen in this study, infection occurred in 19 patients after femur nailing and in 24 patients after tibial nailing (elective 11, emergency 32). These patients were followed by an infections team and required intravenous antibiotic, and surgical debridement was required in 13 cases. Fat embolism occurred in 16 patients (elective 10, emergency 6), and all of them were successfully managed initially in the surgical Intensive Care Unit.

Trauma surgery at night is always challenging, even more so when trained nurses and surgical techniCilt - Vol. 18 SayÄą - No. 4

cians are not familiar with the orthopedic instrumentation. Under these circumstances, any surgery performed could lead to increased risk of complications due to which the patient ultimately suffers.

There are certain limitations of our study: First, this study is retrospective in nature and observational in design; secondly, the etiology of complications reported may be multi-factorial, which was not studied.

In conclusion, the authors believe that a subgroup of patients (closed tibial or femoral nailing) with stable vitals should be operated preferably in the daytime if trained orthopedic staff are not available during the night shift. Saudi Arabia has made strides in medical care comparable to that of developed countries, but there is still room for improvement in the care of trauma patients, particularly the development of dedicated orthopedic trauma theaters with 24-hour availability.

REFERENCES 1. http://www.cdc.gov/ncipc/factsheets/Economic_Burden_of_ Injury.htm.

2. Parrott S. The economic cost of hip fracture in the UK. A paper commissioned by the Department of Trade and Industry. York: Centre for Health Economics, University of York, 2000.

3. Sadat-Ali M, Ahlberg A. Fractured neck of the femur in young adults. Injury 1992;23:311-3.

4. Al-Othman A, Sadat-Ali M. Pattern of paediatric trauma seen in a teaching hospital. Bahrain Med Bull 1994;16:87-9.

5. Al-Bahlool AA, Al-Qahtani SM, Bubshait DA, Sadat-Ali M. Motorcycle-related foot injuries in children. A growing menace. Saudi Med J 2008;29:1675-7.

6. Ansari S, Akhdar F, Mandoorah M, Moutaery K. Causes and effects of road traffic accidents in Saudi Arabia. Public Health 2000;114:37-9.

7. Al-Ghamdi AS. Analysis of traffic accidents at urban intersections in Riyadh. Accid Anal Prev 2003;35:717-24.

8. Al-Habdan I, Sadat Ali, Al-Othman A, Al-Awad N. Injuries due to motorcycle accidents amongst Saudi Women Saudi Medical Journal 1999;20:458-60.

9. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg [Am] 1989;71:336-40.

10. Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma 1985;25:375-84.

11. Pape HC, Aufâ&#x20AC;&#x2122;mâ&#x20AC;&#x2122;Kolk M, Paffrath T, Regel G, Sturm JA, Tscherne H. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion--a cause of posttraumatic ARDS? J Trauma 1993;34:540-8.

12. Harris MB, Gregory SJ. The academic orthopaedic trauma service: an analysis of its financial viability and its impact on resident education and faculty job satisfaction. Presented at Annual Meeting of the Orthopaedic Trauma Association Toronto, 2003.

13. Lemos D, Nilssen E, Khatiwada B, Elder GM, Reindl R, Berry GK, et al. Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre. Can J Surg 2009;52:87-91.

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14. Orthopaedic Trauma Association (OTA) . Fracture and dislocation compendium. OTA. 1996. Available online at: http:// www. ota.org/compendium/humnew.pdf.

15. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58:453-8.

16. Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. 1984. J Bone Joint Surg Am 2001;83A:1912.

17. Ricci WM, Devinney S, Haidukewych G, Herscovici D, Sanders R. Trochanteric nail insertion for the treatment of femoral shaft fractures. J Orthop Trauma 2005;19:511-7.

18. Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15:161-9.

19. Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg 2000;43:256-62.

20. Bhattacharyya T, Vrahas MS, Morrison SM, Kim E, Wiklund RA, Smith RM, et al. The value of the dedicated orthopaedic trauma operating room. J Trauma 2006;60:1336-41.

21. Ricci W, Schwappach J, Leighton R. Is â&#x20AC;&#x153;after hoursâ&#x20AC;? surgery

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associated with adverse outcomes? In: Tornetta P, editor.

Proceedings of the 2005 annual meeting of the Orthopaedic Trauma Association; 2005 Oct. 20-22; Ottawa, Ont. Rosemont, IL: Orthopaedic Trauma Association; 2005. p. 181.

22. Elder GM, Harvey EJ, Vaidya R, Guy P, Meek RN, Aebi M. The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in two trauma centres. Injury 2005;36:10606.

23. Rogers FB, Shackford SR, Keller MS. Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. J Trauma 1995;39:261-5.

24. Lemos D, Nilssen E, Khatiwada B, Elder GM, Reindl R, Berry GK, et al. Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre. Can J Surg 2009;52:87-91.

25. Zagrodnick J, Kaufner HK. Decreasing risk by individualized timing of surgery of para-articular femoral fractures of the hip in the elderly. [Article in German] Unfallchirurgie 1990;16:139-43.

26. Rogers FB, Shackford SR, Vane DW, Kaups KL, Harris F. Prompt fixation of isolated femur fractures in a rural trauma center: a study examining the timing of fixation and resource allocation. J Trauma 1994;36:774-7.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):333-338

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.09735

Management of inhalation injury and respiratory complications in Burns Intensive Care Unit Yanık yoğun bakım ünitesinde inhalasyon yaralanması ve solunum komplikasyonlarının yönetimi Afife Ayla KABALAK, Ahmet Çınar YASTI

BACKGROUND

AMAÇ

Inhalation injury has high mortality and carries a significant risk of permanent pulmonary dysfunction. Inhalation injury and its consequences impose difficulties for the respiratory therapists, nurses and doctors who play a central role in its clinical management. In this study, we aimed to report our clinical experience and the role of non-invasive mechanic ventilatory (NIMV) support in a series of inhalation-injured patients.

İnhalasyon yaralanması yüksek mortalite oranlarına sahiptir ve belirgin kalıcı pulmoner fonksiyon bozukluğu riski taşımaktadır. İnhalasyon yaralanması ve sonuçları, klinik yönetiminde ana rol oynayan solunum terapistlerine, hemşirelere ve doktorlara ciddi zorluklar oluşturur. Çalışmamızda inhalasyon yaralanmalı hasta serimizdeki klinik tecrübelerimizi ve noninvazif mekanik ventilatör (NIMV) desteğinin rolünü bildirmeyi amaçladık.

METHODS

GEREÇ VE YÖNTEM

Patients hospitalized at Ankara Numune Training and Research Hospital’s Burns Intensive Care Unit between March 2009 and March 2011 was reviewed, and patients with required respiratory support due to inhalation injury were included in the study.

Ankara Numune Eğitim ve Araştırma Hastanesi Yanık Yoğun Bakım Ünitesi’nde Mart 2009 - Mart 2011 yılları arasında yatarak tedavi alan hastalardan inhalasyon hasarı nedeniyle solunum desteğine ihtiyaç duyanlar çalışmaya alındı.

RESULTS

BULGULAR

Among the patients, 37 had inhalation injury, and their mortality was 13.5%. Of the 37 patients, 16 had mandatory intubation (6 in the first 6 hours and 10 in the clinical course); however, others (67.8%) had only NIMV support.

Bu hastaların 37’sinde inhalasyon yaralanması vardı, mortalite oranı %13,5 olarak bulundu, hastaların 16’sında zorunlu entübasyon uygulanırken (altı hastada ilk 6 saatte ve 10 hastada klinik seyir sürecinde) diğer hastalara sadece (%67,8) NIMV desteği uygulandı.

CONCLUSION

SONUÇ

Application of NIMV support with proper modes decreases the need for invasive procedures in inhalation-injured patients. Based on our results, we propose the application of NIMV support in inhalation-injured burn patients.

NIMV desteğinin uygun modlarda uygulanması, inhalasyon yaralanmalı olgularda invaziv yöntemlerin gerekliliğini azaltmaktadır. NIMV desteğinin inhalasyon yaralanmalı yanık hastalarında uygulanmasını önermekteyiz.

Key Words: Inhalation injury; medical treatment; respiratory management; ventilatory support.

Anahtar Sözcükler: İnhalasyon yaralanması; medikal tedavi; solunum yönetimi; ventilatör desteği.

Burns Treatment Center, Ankara Numune Training and Research Hospital, Ankara, Turkey.

Ankara Numune Eğitim ve Araştırma Hastanesi Yanık Tedavi Merkezi, Ankara.

Correspondence (İletişim): Afife Ayla Kabalak, M.D. Ankara Numune Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Sıhhiye 06030 Ankara, Turkey.

Tel: +90 - 312 - 508 42 29 e-mail (e-posta): aylakabalak@yahoo.com

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Ulus Travma Acil Cerrahi Derg

Inhalation injury is very common in patients who sustain burns and it has high morbidity and mortality rates. Even isolated inhalation injury can carry a significant risk of mortality or permanent pulmonary dysfunction. When combined with cutaneous burns, inhalation injury increases fluid requirements for resuscitation,[1] the incidence of pulmonary complications,[2] and the mortality rate.[2-4] Inhalation injury is produced by either thermal or chemical irritation due to inspiration of smoke, burning embers, steam, or other irritant or cytotoxic materials in the form of fumes, mists, particulates, or gases.

[3,5,6] The damage can be the result of direct cytotoxic effects of the aspirated materials or a consequence of the inflammatory response. In addition to damage to the airways and pulmonary parenchyma, inhalation of toxic substances such as carbon monoxide or cyanide can produce detrimental systemic effects.[7,8] In recent decades, there has been a dramatic decline in the mortality of large burns. In contrast, despite considerable advances in our knowledge of the pathophysiology of inhalation injury, there are few specific therapeutic options, and patient care is mainly supportive. Although several studies have suggested a decrease in the mortality associated with inhalation injury, these changes would result from overall improvements in care and not so much from interventions aimed specifically at inhalation injury. It is imperative that a well-organized, protocol-driven approach to respiratory management of burn care be utilized so that improvements can be made, and the morbidity and mortality associated with inhalation injury can be reduced.

The goal of this study was to assess whether early application of non-invasive mechanical ventilation (NIMV), medical treatment, respiratory physiotherapy, and nutritional support is effective in a series of inhalation-injured patients.

MATERIALS AND METHODS The medical records of all patients with inhalation injury hospitalized at the Ankara Numune Training and Research Hospital, Burn Treatment Center between 1 March 1 2009 and 1 March 2011 were reviewed. A total of 697 patients were hospitalized, and of them, 234 were inpatients in the intensive care unit (ICU) of the Burns Center. Of the ICU patients, 97 required respiratory support due to acute respiratory failure. While inhalation injury was the diagnosis in 37 patients, others had secondary pulmonary damage, acute respiratory distress syndrome (ARDS), sepsis, and multi-organ failure on their first admission to hospital.

Inhalation injury was documented based on history, physical findings, arterial blood gas monitoring, serial 334

chest radiography, and serial fiberoptic bronchoscopy in all cases. Indication for the endotracheal intubation and ventilation and PaO2/FiO2 values of the patient just prior to institution of invasive positive pressure ventilation (IPPV) and/or non-invasive positive pressure ventilation (NIPPV) were noted. The cause of respiratory failure, ventilator modes, pressures, and whether intubation/re-intubation was done were also recorded.

The diagnosis of pneumonia was made regarding presence of hyperthermia (>38.2°C), leukocytosis (white blood cells [WBC] >15x109/L), positive sputum cultures, and radiographic identification of infiltrates.

IPPV and NIPPV were delivered using Nellcor Prutan Bennett 840 ventilators. The BiLevel Positive Airway Pressure+Pressure Control mode with timed cycling (BiLevel+PC) was used for IPPV. Bilevel+PC ventilation provides two ventilatory pressures: The Inspiratory Positive Airway Pressure (PEEPhigh) and the Expiratory Positive Airway Pressure (PEEPlow).

Pressure support ventilation has been shown to improve tidal volume, gas exchange, respiratory rate, and diaphragmatic activity in proportion to the amount of pressure supplied. The Continuous Positive Airway Pressure (CPAP) ventilation mode was used for NIPPV at spontaneous breathing. CPAP prevents or helps re-open collapsed alveoli and atelectasis of lung zones and is often used to facilitate weaning.

NIPPV was applied to patients who were hemodynamically stable, conscious and alert. IPPV is the choice of procedure at endotracheal intubation to protect the airway (large facial burn, obstructive airway edema) or to remove excessive tracheobronchial secretions or in case of large facial burn. Evidence of acute respiratory failure had to be exhibited by the patient, and this was defined as acute hypoxemia where the PaO2/FiO2 ratio was ≤40 kPa. This value is part of the definition for an acute lung injury (ALI).

The pressures for NIPPV (CPAP) set on the ventilator were kept low initially (Ppeak = 8-10 cmH2O, PEEP = 8 cmH2O). NIPPV was used every 2 hours (h) for 15-minute (min) periods. Most patients were allowed to remove their masks for a few minutes for talking, mobilization or in some cases to drink small amounts of water.

The pressures for IPPV (BiLevel + PC) set on the ventilator were low initially (PEEP high: PEEP low + Psupport = 10-12 cmH2O, PEEP low = 4-6 cmH2O).

The pressures were titrated upwards according to the patient’s tolerance and arterial blood gas results (the maximum pressures used were PEEP high: PEEPlow + Psupport = 23 cmH2O, PEEP low = 8 cmH2O).

All patients received chest physiotherapy while on NIPPV and IPPV to assist expectoration of secretions Temmuz - July 2012

Management of inhalation injury and respiratory complications in Burns Intensive Care Unit

and reversal of atelectasis, twice daily in routine practice and additionally where required. A saline nebulizer was in the circuit and, if prescribed, bronchodilator, heparin, N-acetylcysteine (NAC), and corticosteroid was given. Bed positions were changed frequently in all patients. Fluid-electrolyte replacement, intravenous vitamin C and nutritional support with a high content of protein were performed in all patients.

Age, sex, burned total body surface area (TBSA), and whether burn surgery was performed were recorded for all patients.

RESULTS All patients received routine burn management, mechanical ventilation and supportive treatment according to the Unit’s protocols. A total of 37 patients were included in the study. Baseline characteristics and the clinical course of the patients are shown in Table 1. There were four females, the mean age was 41 years (21-76 years), and burned TBSA was a mean 28.2% (range: 18-54%). The etiologies of the injuries were flame and smoke, and the diagnosis was made by fiberoptic bronchoscope examination in 31 patients; the remaining six patients sustained large burns to the face. A total of 29 patients underwent burns surgery and 24 had early excision of deep partial-thickness and full-thickness burns. Wound closure was achieved either temporarily by wound dressing and/or using skin substitutes or permanently with split thickness auto grafts. The pre-morbid conditions of the patients are summarized in Table 2. Some of the victims had additional traumas at the time of the inhalation injury (Table 3).

Six patients required urgent endotracheal intubation and invasive mechanical ventilation (IMV) support (because of extensive facial burn) for a period of 1-29 days. Ventilator support was continued with NIPPV after extubation. NIPPV was well tolerated by the patients in general. Regarding the patient records, low pressures were initiated until the patient cooperated to breathe on the ventilator. NIPPV was used for prophylaxis in 21 patients (PaO2/FiO2 >40 kPa) to prevent further respiratory deterioration and endotracheal intubation or re-intubation. Therapeutic NIPPV was applied to 10 patients with PaO2/FiO2 ratio <40 kPa. Pneumonia suspicion was documented in 25 patients. Of these 25, eight patients received IPPV as they were accepted to have high risk of developing respiratory complications after sustaining sepsis, systemic inflammatory response syndrome (SIRS), ARDS, pleurisy, and hemopneumothorax (3 patients had 1 and 2 had 2 re-intubations). Postoperatively, two patients had continuous ventilator support for 2-3 days and shift to NIPPV in the following days. Four patients with severe inhalation injury requiring longCilt - Vol. 18 Sayı - No. 4

Table 1. Demographics and clinical course of

the patients Variable

Patients

Number of patients 37 Age (mean, in year) 41.38 (range: 21-76) Female/Male 4/27 TBSA (mean %) 28.2 (range: 18-54) Facial burns (extensive/mild) 6/21 Burns surgery 29 Diagnostic fiberoptic bronchoscopy 31 Intubated and ventilated (emergency/late period) 6/10 Tracheostomy 4 Ventilation days (mean) 8.1 (range 1-29) TBSA: Total body surface area.

Table 2. Pre-morbid conditions of the patients Medical condition/surgery Chronic obstructive pulmonary disease Hypertension Diabetes mellitus Left-ventricular failure Right-ventricular failure Chronic renal failure Epilepsy Dementia Schizophrenia Stroke Carcinoma of the prostate

Patients 8 8 7 5 1 4 3 2 1 1 1

Table 3. Additional injuries sustained by the patients Nature of injury Head injury Subarachnoid hemorrhage Hemopneumothorax Extremity fractures Tendon ruptures

Patients 1 1 1 2 2

term ventilator support and frequent tracheal toilet underwent tracheostomy procedure.

The most common cause of respiratory deterioration is shown in Table 4. In some patients, while pneumonia was the primary cause, another respiratory pathology was deemed to contribute to the acute respiratory failure.

Our Burn Center’s routine pulmonary treatment protocol is summarized in Table 5.

Emergent intubation and mechanical ventilation were indicated in six patients (16.2%). Intubation/reintubation was successfully avoided in 21 of the 37 335

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Table 4. The cause of acute respiratory failure Cause Upper airway edema Pneumonia Bronchospasm SIRS ARDS Pleurisy

Patients 6 25 12 6 4 9

SIRS: Systemic inflammatory response syndrome; ARDS: Acute respiratory distress syndrome.

Table 5. Medical and supportive treatment protocols for lung healing Treatment modalities Chest physiotherapy Position change Prone position Saline nebulizer, inhaler Heparin nebulizer, inhaler NAC nebulizer, inhaler Corticosteroid nebulizer, inhaler Bronchodilator Tracheal aspiration Tracheal lavage Bronchoalveolar lavage by fiberoptic bronchoscopy Recruitment maneuver

Ventilatory modes NIPPV / IPPV NIPPV / IPPV NIPPV NIPPV / IPPV NIPPV / IPPV NIPPV / IPPV NIPPV / IPPV NIPPV / IPPV IPPV IPPV IPPV IPPV

(56.7%) patients (Table 6). Intubation/re-intubation and IMV were indicated due to acute respiratory failure and hemodynamic instability in 10 (32.2%) of the 31 patients.

The patientsâ&#x20AC;&#x2122; outcomes after treatment for the 37 patients are demonstrated in Table 7. Five patients died due to multi-organ failure as a result of burns with inhalation injury.

DISCUSSION Inhalation injury is a nonspecific term describing the harmful effects of inspiration of any of a large number of materials that can damage the airways or pulmonary parenchyma. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury.[9] The pathology of the upper and lower respiratory tract lesions is due to the formation of edema, mucosal casts, and tenacious secretions.[3] Focal areas of congestion and edema are seen, alternating with the areas of collapse and pneumonia, which are the results of compensatory emphysema.[7] As a result, pulmonary compliance decreases, which can be more than 50%. In severe injuries, physiologic shunt lead336

Table 6. Respiratory results of patients treated with NIPPV and IPPV Ventilatory support

Patients Percentage

Emergency intubation 6/37 Intubation/reintubation 16/37 Intubation/reintubation (after NIPPV) 10/31

16.2 43.7 32.2

NIPPV: Non-invasive positive pressure ventilation; IPPV: Invasive positive pressure ventilation.

Table 7. Patient outcomes Outcome

Patients Percentage

Self-ventilation COPD requiring treatment Mortality

23 9 5

62 35 13.5

COPD: Chronic obstructive pulmonary disease.

ing to profound hypoxemia and acute microvascular injury with increased transvascular fluid flux produces a clinical picture of ARDS. Furthermore, in burn patients, multiple mechanisms, besides inhalation injury, may contribute to ALI (e.g., sepsis, ventilator-induced injury, or SIRS to the burns).[10] In the clinical setting, diagnosis of inhalation injury is usually a subjective decision based on a combination of history and physical examinations, and is confirmed by diagnostic studies (e.g., fiberoptic bronchoscopy, xenon scanning, carboxyhemoglobin level, estimation of extravascular lung water by thermal and dye dilution). Defining the diagnostic criteria for inhalation injuries is complicated due to the extreme heterogeneity of clinical presentation as evaluated by the criteria above. Another difficulty is encountered when one attempts to distinguish between exposure to inhaled irritants and inhalation injury. Our clinical experience is that progressive respiratory failure does not always appear proportional to the exposure to smoke. These differences are likely due to the composition of the inhaled materials and/or differences in host response such as levels of antioxidants or inflammatory response.[11] Bronchoscopy of the airway is still the gold standard to detect a pathognomonic mucosal hyperemia. Chest radiographs may show signs of diffuse atelectasis, pulmonary edema or bronchopneumonia. However, during the initial period, the degree of injury is usually underestimated based on the chest X-ray, as the injury is mainly confined to the airways.[12] There is no consensus regarding standards for treatment of inhalation injury; however, treatment options are determined by the availability of resources and local tradition.[13] Patients with combined smoke inhalation injury and cutaneous burns are well known to Temmuz - July 2012

Management of inhalation injury and respiratory complications in Burns Intensive Care Unit

be more hemodynamically unstable than patients with cutaneous burn injury alone. Acute airway obstruction is a major hazard because of the possibility of rapid progression (the first 12 h after insult). For patients with large surface burns that require rapid fluid administration, these changes may be accentuated.[14] Endotracheal intubation and PPV are commonly used to prevent or treat hypoxia and to secure a patent airway in the patient.[15] Ventilation protocols differ not only between different burn centers but also between individual physicians. Apart from conventional pressure-controlled low tidal volume ventilation, multiple strategies for mechanical ventilation are currently in use for the treatment of smoke inhalation injury, isolated as well as in combination with burns. Upper airway injuries and their sequelae continue to be major management problems in the care of patients with burn and inhalation injuries. However, the presence of the endotracheal tube introduces problems by bypassing the protective mechanisms of the upper airway, increasing the incidence of nosocomial pneumonia and damage to the airway resulting in tracheal stenosis.[16] Factors contributing to the risk of developing acute respiratory complications in burn patients include ventilatory restriction caused by the pain and tightness of abdominal and chest burns, autografts and donor sites.

The presence of injuries to the thoracic cage or within lung tissue compounded the restriction and introduced problems with sputum retention and airway plugging.

One other factor that we found to increase the risk of respiratory complications is frequent general anesthesia. This is associated with reduced lung volumes and is necessary with a major burn-injured patient to enable wound care and surgical procedures. To avoid anesthesia-induced pulmonary complications, indications for surgery must be determined while taking its likelihood into consideration. Also, patients who are immobilized in bed for prolonged periods of time have a reduced functional residual capacity and therefore are more likely to develop airway atelectasis. Prophylaxis with NIPPV can be applied to prevent further respiratory complications.[17] In our burn-injured patients with acute respiratory failure, NIPPV appears to be effective in supporting respiratory function such that endotracheal intubation could be avoided in most cases. Moreover, we also found that NIPPV facilitated earlier weaning of mechanical ventilation and extubation. Once the patient is established on the ventilatory support, they are extubated and commenced on mask ventilation, which consequently provides earlier initiation of an active rehabilitation program. However, the patient must fulfill the selection criteria for NIPPV to ensure a smooth transition from IMV to NIPPV and ultimately to selfventilation. During the last two decades, IMV has been Cilt - Vol. 18 Say覺 - No. 4

studied extensively. Low tidal volume ventilation with associated permissive hypercapnia has been shown to effectively reduce ventilator-induced lung injury, and currently represents the standard of care.[18] Appropriate fluid resuscitation in patients with smoke inhalation injury is still subject to controversial debates.[19] This, of course, does not inevitably indicate that isolated smoke inhalation injury is associated with increased fluid requirements. By contrast, overresuscitation may increase pulmonary microvascular pressures and might thereby lead to increased edema formation under the high permeability conditions in early lung injury. In our opinion and based on the literature, fluid resuscitation should be guided by urinary output and hemodynamic parameters of the individual patient. In this regard, dynamic parameters, such as change in pulse pressure, rather than static parameters, such as central venous or pulmonary artery occlusion pressures, might be helpful.[20] Contrary to popular belief that the lung is the primary injured organ following smoke inhalation injury and that mechanical ventilation is frequently necessary, administration of therapeutic compounds via nebulization directly to the affected organ seems to be more reasonable. Based on the complex pathogenesis of smoke inhalation injury, drugs with different mechanisms of action, such as bronchodilators, anticoagulants, antioxidants, and corticosteroids, have been studied. In each case, however, the key to any successful aerosol therapy is to deliver into the lung and to the distal airways. Owing to increased procoagulatory activity following smoke inhalation injury,[21] the aerolized administration of anticoagulants seems to be more than promising. In a bovine model, Brown et al.[22] first described a reduction in mortality after smoke inhalation-induced ARDS by using aerolized heparin. In children with combined burn and smoke inhalation injury, nebulization of heparin and NAC significantly decreased re-intubation rates, the incidence of atelectasis and mortality.[23] We observed that nebulization of heparin and NAC was beneficial in patients. Aerolized epinephrine or corticosteroids have been proposed as therapeutic approaches in progressive upper airway edema;[15] however, conclusive evidence for these treatment strategies is still lacking.

We prefer to initiate with aerolized corticosteroids for the first four days and than shift to intravenous route.

As mentioned earlier, following combined burn and smoke inhalation injury, the oxidative-antioxidative balance is disturbed by an increase in reactive oxygen species and a parallel decrease in antioxidants. Accordingly, the antioxidant vitamin C, E or 帢-tocopherol is markedly reduced in patients with major burns and combined smoke inhalation injury.[24,25] We prefer to give intravenous vitamin C as an antioxidant. In our 337

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experience, administration of anticoagulants, antioxidants and bronchodilators currently represent the most promising effective treatment strategies.

Against the background of the current literature, there has been a remarkable increase in our knowledge regarding the pathogenesis of smoke inhalation injury during the last two decades. There are several promising therapeutic approaches, such as bronchodilators, antioxidants or anticoagulants, and nebulization of the use of different ventilation modes. In inhalation-injured patients with acute respiratory failure, NIPPV appears to be effective in supporting respiratory function such that endotracheal intubation can be avoided in most cases. There is a need for further researches and multi-center trials to acquire a larger sample size, and prospective studies would enable standardization of monitoring. To achieve this goal, the cooperation and communication between burn centers should be intensified.

REFERENCES 1. Dai NT, Chen TM, Cheng TY, Chen SL, Chen SG, Chou GH, et al. The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries.

Burns 1998;24:671-5.

2. Shirani KZ, Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury and pneumonia on burn mortality. Ann Surg 1987;205:82-7.

3. Head JM. Inhalation injury in burns. Am J Surg 1980;139:50812.

4. Tredget EE, Shankowsky HA, Taerum TV, Moysa GL, Alton JD. The role of inhalation injury in burn trauma. A Canadian experience. Ann Surg 1990;212:720-7.

5. Haponik E. Smoke inhalation injury: some priorities for respiratory care professionals. Resp Care 1992;37:69-612.

6. Einhorn IN. Physiological and toxicological aspects of smoke produced during the combustion of polymeric materials. Environ Health Perspect 1975;11:163-89.

7. Walker HL, McLeod CG Jr, McManus WF. Experimental inhalation injury in the goat. J Trauma 1981;21:962-4.

8. Nieman GF, Clark WR Jr, Wax SD, Webb SR. The effect of smoke inhalation on pulmonary surfactant. Ann Surg 1980;191:171-81.

9. Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009;3:283-297.

10. Enkhbaatar P, Traber DL. Pathophysiology of acute lung in-

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jury in combined burn and smoke inhalation injury. Clin Sci (Lond) 2004;107:137-43.

11. Sherwood ER, Toliver-Kinsky T. Mechanisms of the inflammatory response. Best Pract Res Clin Anaesthesiol 2004;18:385-405.

12. Lee MJ, Oâ&#x20AC;&#x2122;Connell DJ. The plain chest radiograph after acute smoke inhalation. Clin Radiol 1988;39:33-7.

13. Woodson LC. Diagnosis and grading of inhalation injury. J Burn Care Res 2009;30:143-5.

14. Haponik EF, Meyers DA, Munster AM, Smith PL, Britt EJ, Wise RA, et al. Acute upper airway injury in burn patients.

Serial changes of flow-volume curves and nasopharyngoscopy. Am Rev Respir Dis 1987;135:360-6.

15. Fitzpatrick J, Cioffi Jr. WG. Diagnosis and treatment of inhalation injury. In: Herndon D, editor. Total burn care. London: Saunders; 1996. p. 184-92.

16. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.

17. Smailes ST. Noninvasive Positive Pressure Ventilation in burns. Burns 2002;28:795-801.

18. Peck MD, Koppelman T. Low-tidal-volume ventilation as a strategy to reduce ventilator-associated injury in ALI and ARDS. J Burn Care Res 2009;30:172-5.

19. Cancio LC, ChĂĄvez S, Alvarado-Ortega M, Barillo DJ, Walker SC, McManus AT, et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients.

J Trauma 2004;56:404-14.

20. Soejima K, Schmalstieg FC, Sakurai H, Traber LD, Traber DL. Pathophysiological analysis of combined burn and smoke inhalation injuries in sheep. Am J Physiol Lung Cell Mol Physiol 2001;280:L1233-41.

21. Enkhbaatar P, Herndon DN, Traber DL. Use of nebulized heparin in the treatment of smoke inhalation injury. J Burn Care Res 2009;30:159-62.

22. Brown M, Desai M, Traber LD, Herndon DN, Traber DL. Dimethylsulfoxide with heparin in the treatment of smoke inhalation injury. J Burn Care Rehabil 1988;9:22-5.

23. Desai MH, Mlcak R, Richardson J, Nichols R, Herndon DN. Reduction in mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcystine [correction of acetylcystine] therapy. J Burn Care Rehabil 1998;19:2102.

24. Nguyen TT, Cox CS, Traber DL, Gasser H, Redl H, Schlag G, et al. Free radical activity and loss of plasma antioxidants, vitamin E, and sulfhydryl groups in patients with burns: the 1993 Moyer Award. J Burn Care Rehabil 1993;14:602-9.

25. Kahn SA, Beers RJ, Lentz CW. Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review. J Burn Care Res 2011;32:110-7.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):339-343

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.61257

The impact of Ramadan on peptic ulcer perforation Peptik ülser perforasyonuna Ramazan’ın etkisi Ali Kağan GÖKAKIN, Atilla KURT, Mustafa ATABEY, Ayhan KOYUNCU, Ömer TOPÇU, Cengiz AYDIN, Metin ŞEN, Gündüz AKGÖL BACKGROUND

AMAÇ

Medical treatment has played an important role in the reduction of peptic ulcer perforation (PUP). The goal of this study was to evaluate the effect of fasting on PUP.

Medikal tedavi peptik ülser perforasyon (PÜP) oranlarının azalmasında önemli bir rol oynamıştır. Bu çalışmada, Ramazan ayının PÜP üzerine olan etkisi değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

A retrospective analysis of 229 patients who were operated due to PUP between 1999-2009 was made. Patients were divided into two groups. Group I (n=188) included the patients who were operated in other periods of the year, while Group II (n=41) included the patients who were operated during Ramadan, the Muslim period of fasting. Patients in Group II were analyzed in terms of duration of fasting.

PÜP nedeniyle 1999-2009 yılları arasında ameliyat edilen 229 hastanın dosyaları geriye dönük olarak analiz edildi. Hastalar iki gruba ayrıldı. Grup I (n=188) Ramazan ayı dışında ameliyat edilen hastalar, Grup II (n=41) Ramazan ayında, müslümanların oruç tutma döneminde ameliyat edilen hastalar. Grup II’deki hastalar oruç tutma sürelerine göre de değerlendirildi.

RESULTS

BULGULAR

The increase in surgeries per group was higher in Group II than Group I (p<0.05). Predisposing factors, anti-ulcer drug usage and demographic variables were seen to have no role in this difference. Duration of fasting may have a minimal effect on the perforation.

Grup başına düşen ameliyat sayısı Grup II’de daha fazla idi (p<0.05). Bu farkın oluşmasında predispozan faktörler, antiülser ilaç kullanımı ve demografik özelliklerin rolü olmadığı saptandı. Oruç tutma süresinin perforasyon üzerine küçük bir etkisi olabileceği görüldü.

CONCLUSION

SONUÇ

The results of this study demonstrate that PUP is detected as relatively higher during Ramadan among those who are fasting for more than 12 hours daily. We suggest that people with predisposing factors should be informed before making a decision to fast.

Bu çalışmanın verileri Ramazan orucunun günde 12 saatten daha fazla sürdüğü dönemlerde PÜP’nin rölatif olarak daha fazla görüldüğünü göstermektedir. Predispozan faktöktörü olan hastaların oruç kararı öncesi bilgilendirilmesi gerektiği kanısındayız.

Key Words: Acute abdomen; peptic ulcer perforation; prolonged fasting; Ramadan; urgent surgery.

Anahtar Sözcükler: Akut karın; peptik ülser perforasyonu; uzamış açlık; Ramazan; acil cerrahi.

The therapeutic options in peptic ulcer disease, which includes ulcers of the duodenum and stomach, continue to be ameliorating due to the progress in surgical techniques, microbiology, and drug therapy. Yet, there is still a debate regarding the proper management of complicated peptic ulcer disease and, in particular,

of those that are perforated.[1] A variety of therapeutic approaches have been offered for the treatment of peptic ulcer perforation (PUP) in the literature, such as nonoperative management, laparoscopic repair and upper midline laparotomy.[2-5] However, the routine treatment for perforated peptic ulcer still seems to be

Department of General Surgery, Cumhuriyet University Faculty of Medicine, Sivas, Turkey.

Cumhuriyet Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Sivas.

Correspondence (İletişim): Ali Kağan Gökakın, M.D. Cumhuriyet Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı, 058140 Sivas, Turkey.

Tel: +90 - 346 - 258 04 91 e-mail (e-posta): dralihan20@hotmail.com

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ritual on PUP have not been thoroughly studied in recent years. Furthermore, an ongoing debate remains on peptic ulcer patients as to whether or not they may fast during Ramadan. This study was organized to evaluate the impact of Ramadan on PUP by considering the medical conditions of the patients and the duration of the fasting period (daylight) during Ramadan.

by upper laparotomy, representing the main motive for reviewing the literature.[6] The introduction of proton pump inhibitors and H2 antagonists into clinical use together with the recognition of Helicobacter pylori have caused a dramatic improvement in the medical management of uncomplicated peptic ulcer. In fact, the surgical approach to uncomplicated peptic ulcer disease has basically disappeared.

MATERIALS AND METHODS The study was organized in a retrospective manner and involved 229 patients who were operated at our hospital for PUP between January 1999 and December 2009. Patients were divided into two groups. Group I included the patients who were operated in the months other than Ramadan (110 months during the study period), while Group II included the patients who were operated and declared their fasting during Ramadan (10 months during the study period). Any medical conditions of the patients that may have had an effect on the perforation, such as age, gender, period of time, concomitant disease, use of anti-ulcer drugs at the time of admission, and duration of daylight during the month of Ramadan were evaluated.

The cause of the perforation is unclear, but smoking, alcohol, non-steroidal antiinflammatory drug (NSAID) medication, and H. pylori infection have been identified as facilitating factors in many publications.[7-11] Up to 30% risk of mortality can be seen in surgery for perforated ulcer.[12,13] The factors that could be associated with mortality and morbidity in this group of patients have been the subject of many retrospective and prospective studies.

Age, gender, type of surgery, chronic disease, drug and alcohol use, duration of perforation, blood pressure, concomitant disease, renal failure, and liver cirrhosis have been detected as the factors associated with morbidity in various publications.[14-22]

Statistics

Fasting during the ninth month of the lunar calender (Ramadan) is a religious obligation for all adult Muslims. This entails no food or liquid intake from sunrise to sunset. The duration of this restriction varies between 10 to 19 hours depending on the season of the solar calendar in which Ramadan coincides that year (approximately 10 days earlier every year). The effect of Ramadan on the metabolism of the body has been the subject of various publications.[23-28] An association between time-restricted food and water intake and gastric pH and plasma gastrin level has been known for a long time.[29]

We applied SPSS (Statistical Package for the Social Sciences) for Windows 15.0 for statistical analysis. The results were shown as percentages or median, minimum and maximum. Categorical data were analyzed statistically with chi-square. Continuous data were evaluated using Mann-Whitney U test.

RESULTS Groups I and II included 188 (82.1%) and 41 (19.9%) patients, respectively. The number of surgeries per group was statistically significantly higher in Group II compared to Group I (p<0.05). In the study, covering 120 months, both groups were exam-

However, some particular effects of this religious Table 1. Distribution of operations per month

Number of cases Mean value of operations per month

p

Total months (120 Months)

Group I (110 Months)

Group II (10 Months)

229 (100%) 1.90

188 (82.1%) 1.70

41 (17.9%) 4.10

p <0.001

Chi-square test.

Table 2. Demographics of patients in groups

Group I

Group II

p

Age Gender (Male/Female)

46 (16-85) 165/23 (87.8/12.2)

44 (18-76) 30/11 (73.2/26.8)

0.417 0.017

Mann-Whitney U and chi-square for age and gender, respectively.

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Temmuz - July 2012

The impact of Ramadan on peptic ulcer perforation

Table 3. Clinical features of patients

Generation Young adult Geriatric Medication Positive Negative Comorbidity Positive

Group I

Group II

132 (70.22) 56 (29.79)

36 (19.15) 152 (80.86)

90 (47.88)

33 (80.49) 8 (19.52)

8 (19.52) 33 (80.49)

17 (41.47)

p 0.184 0.957 0.456

Chi-square test.

Table 4. Impact of the length of fasting time on perforation in Group II Duration

n

%

p

More than 12 hours Less than 12 hours Total

33 8 41

80.5 19.5 100

p<0.001

Chi-square test.

ined in terms of the number of operations per month, and the number was statistically significantly higher in Group II (Table 1). Overall hospital mortality rate was detected as six (2.6%) during the study period.

The ages of the patients ranged from 16 to 85 years (median: 45.0 [16-85]). The majority of the patients were male (n=195, 85.2%) and younger than 60 years (n=165, 72.1%). There was no difference between the two groups in terms of age (p=0.417), but the number of males was significantly higher in Group II (p=0.017). The incidence of perforation was detected as higher in young adults when the patients were analyzed according to their generation (older or younger than 60 years), but the difference was not statistically significant (Table 2).

In both groups, the majority of patients were not using any anti-ulcer drug (H2 receptor blocker, proton pump inhibitor or antibiotics for H. pylori eradication) (80.86%, 80.49% in Groups I and II, respectively) at the time of admission. Approximately one of two patients in each group (44% of all patients) had at least one concomitant disease. However, both comorbidities and anti-ulcer therapy usage at the time of admission were detected as ineffective in terms of statistical meaning between the two groups (Table 3).

The duration of fasting was analyzed in Group II patients, and PUP was found to be significantly higher in the patients who fasted more than 12 hours (p<0.001) (Table 4).

DISCUSSION The question of whether or not fasting should be Cilt - Vol. 18 Say覺 - No. 4

recommended to peptic ulcer disease patients is difficult because the physiological changes during Ramadan are not precisely known. The goal of this study was to evaluate the effect of Ramadan fasting on the occurrence of PUP. In the modern era of H2-receptor blocker/proton pump inhibitor and H. pylori eradication treatment for peptic ulcer disease, there has already been a sharp decline in the elective treatment of such diseases. On the other hand, during this time, there has been no fall in the rates of PUP. Perforation of an ulcer is one of the most serious complications of peptic ulcer disease and has a great potential risk of morbidity and even lethality. The risk of this lethality lasted until the turn of the twentieth century when surgical treatment became available.[30,31] The overall hospital mortality rate was six (2.6%) in our study. This rate of mortality is acceptable and compatible with the literature.[9,16] It is well known that gastrointestinal disorders can be altered by fasting. Recently, only a few studies have focused on the impact of Ramadan on peptic disorders, and these have all reported different results.[23,26] In our study, both groups were examined in terms of the number of operations per month per group.

The number of operations was significantly higher in Group II (p<0.05), and these results seem consistent with previous studies.[32,33] Peptic ulcer disease is mostly seen in male adults.

The incidence of perforation was detected as higher in young adults in our study when the patients were analyzed according to their generation

[7,9,12,16,17]

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Ulus Travma Acil Cerrahi Derg

(as older or younger than 60 years), but no statistical significance was found. However, interestingly, the number of males were significantly higher in Group II (p=0.017). This male dominancy can be explained by the different gender conditions. Men have to continue this ritual through the month without a break. On the other hand, women are permitted a few days of break from the fast during their menstrual period.

Concomitant disease has been detected as a factor associated with incidence and morbidity in many publications.[19,20] In our study, at least half of the patients suffered from a concomitant disease (54.1%), but no difference was found between the two groups.

Prolonged fasting has been shown to affect many things including metabolic profiles, weight, kidney function, blood pressure, and diabetes mellitus control.[27,28] Thus, it can easily be expected that the duration has an effect on the rates of perforation. When the impact of the duration of fasting was analyzed in Group II patients, PUP was found significantly higher in patients who were fasting more than 12 hours (p<0.001).

This study has some limitations. Acquisition of all the relevant data requires a perspective of 36 years because Ramadan completes its progression around the solar calender in 36 years. Furthermore, this study can reflect only the results of one region in Turkey, but there are more than one billion Muslims throughout the world who are fasting under different conditions and durations.

In conclusion, a significant difference was found in the frequency of PUP during Ramadan, especially when the period of fasting was longer than 12 hours.

On the other hand, it seems safe for other individuals.

Further studies are required to obtain more comprehensive results.

REFERENCES 1. Christensen A, Bousfield R, Christiansen J. Incidence of perforated and bleeding peptic ulcers before and after the introduction of H2-receptor antagonists. Ann Surg 1988;207:4-6.

2. Bhogal RH, Athwal R, Durkin D, Deakin M, Cheruvu CN. Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg 2008;32:2371-4.

3. Song KY, Kim TH, Kim SN, Park CH. Laparoscopic repair of perforated duodenal ulcers: the simple “one-stitch” suture with omental patch technique. Surg Endosc 2008;22:1632-5.

4. Vaidya BB, Garg CP, Shah JB. Laparoscopic repair of perforated peptic ulcer with delayed presentation. J Laparoendosc Adv Surg Tech A 2009;19:153-6.

5. Songne B, Jean F, Foulatier O, Khalil H, Scotté M. Non operative treatment for perforated peptic ulcer: results of a prospective study. [Article in French] Ann Chir 2004;129:57882.

6. Bertleff MJ, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 342

2010;24:1231-9.

7. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg 2000;24:277-83.

8. Doherty GM, Way LW. Stomach and duodenum. In: Doherty GM, Way LW, editors. Current surgical diagnosis and treatment. 11th ed. New York: McGraw-Hill; 2003 p. 533-64.

9. M. Johnston D, Martin I. Duodenal ulcer and peptic ulceration. In: Zinner JZ, Schwartz SI, Ellis H, editors. Maingot’s abdominal operations. 10th ed. Vol. 1., Connecticut: Appleton&Lange; 1997. p. 941-70.

10. Irvin TT. Mortality and perforated peptic ulcer: a case for risk stratification in elderly patients. Br J Surg 1989;76:215-8.

11. Martin RF. Surgical management of ulcer disease. Surg Clin North Am 2005;85:907-29, vi.

12. Rajesh V, Chandra SS, Smile SR. Risk factors predicting operative mortality in perforated peptic ulcer disease. Trop Gastroenterol 2003;24:148-50.

13. Gisbert JP, Pajares JM. Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment. Helicobacter 2003;8:159-67.

14. Chou NH, Mok KT, Chang HT, Liu SI, Tsai CC, Wang BW, et al. Risk factors of mortality in perforated peptic ulcer. Eur J Surg 2000;166:149-53.

15. Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease today-indication, technique and outcome. Langenbecks Arch Surg 2000;385:84-96.

16. Chalya PL, Mabula JB, Koy M, McHembe MD, Jaka HM, Kabangila R, et al. Clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience. World J Emerg Surg 2011;6:31.

17. Torab FC, Amer M, Abu-Zidan FM, Branicki FJ. Perforated peptic ulcer: different ethnic, climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates. Asian J Surg 2009;32:95-101.

18. Kujath P, Schwandner O, Bruch HP. Morbidity and mortality of perforated peptic gastroduodenal ulcer following emergency surgery. Langenbecks Arch Surg 2002;387:298302.

19. Barut I, Tarhan OR, Cerci C, Karaguzel N, Akdeniz Y, Bulbul M. Prognostic factors of peptic ulcer perforation. Saudi Med J 2005;26:1255-9.

20. Lanas A. Gastrointestinal injury from NSAID therapy.

How to reduce the risk of complications. Postgrad Med 2005;117:23-8, 31.

21. Noguiera C, Silva AS, Santos JN, Silva AG, Ferreira J, Matos E, et al. Perforated peptic ulcer: main factors of morbidity and mortality. World J Surg 2003;27:782-7.

22. Mäkelä JT, Kiviniemi H, Ohtonen P, Laitinen SO. Factors that predict morbidity and mortality in patients with perforated peptic ulcers. Eur J Surg 2002;168:446-51.

23. Al-Hourani HM, Atoum MF. Body composition, nutrient intake and physical activity patterns in young women during Ramadan. Singapore Med J 2007;48:906-10.

24. Fedail SS, Murphy D, Salih SY, Bolton CH, Harvey RF. Changes in certain blood constituents during Ramadan. Am J Clin Nutr 1982;36:350-3.

25. Ramadan J, Telahoun G, Al-Zaid NS, Barac-Nieto M. Responses to exercise, fluid, and energy balances during Ramadan in sedentary and active males. Nutrition 1999;15:735-9.

26. Larijani B, Zahedi F, Sanjari M, Amini MR, Jalili RB, Adibi H, et al. The effect of Ramadan fasting on fasting serum gluTemmuz - July 2012

The impact of Ramadan on peptic ulcer perforation

cose in healthy adults. Med J Malaysia 2003;58:678-80.

27. Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care 2010;33:1895902.

28. Ghouri N, Gatrad R, Sattar N, Dhami S, Sheikh A. Summerwinter switching of the Ramadan fasts in people with diabetes living in temperate regions. Diabet Med 2012;29:696-7.

29. Halberg F. Protection by timing treatment according to bodily rhythms-an analogy to protection by scrubbing before sur-

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gery. Chronobiologia 1974;1:27-72.

30. Jennings D. Perforated peptic ulcer. Lancet 1940;1:444.

31. Jennings D. Perforated peptic ulcer. Lancet 1940;1:395.

32. Bener A, Derbala MF, Al-Kaabi S, Taryam LO, Al-Ameri MM, Al-Muraikhi NM, et al. Frequency of peptic ulcer disease during and after Ramadan in a United Arab Emirates hospital. East Mediterr Health J 2006;12:105-11.

33. Jastaniah S, Al Naami MY, Malatani TM. Perforated duodenal ulcer in Asir central hospital. Saudi J Gastroenterol 1997;3:90-3.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):344-346

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.87059

Surgical treatment of a case with rapidly growing mass lesion after trauma: on the left forearm arteriovenous malformation Travma sonrası hızlı büyüyen kitlesi olan bir olgunun cerrahi tedavisi: Sol ön kolda arteriyovenöz malformasyon Süreyya TALAY,1 Bilgehan ERKUT,1 Mehmet Eşref KABALAR2

In this case, we report a vascular malformation with high flow pattern complicated with trauma. A postoperative histopathology examination confirmed an arterio-venous malformation in specimens of surgical excision material. In our opinion, posttraumatic progression of a vascular malformation is an emergency and requires an urgent evaluation with surgery at any localization of the body.

Biz bu olguda, travma sonrası yüksek flow paternine sahip bir vasküler malformasyon olgusunu sunduk. Cerrahi sonrası hastada histopatolojik olarak arteriyovenöz malformasyon tanısı kondu. Bizim düşüncemize göre vücudun herhangi bir yerinde travma sonrası gelişen progresif olarak gelişme gösteren vasküler malformasyonlarda acil ve hızlı bir cerrahi uygulanması gereklidir.

Key Words: Arteriovenous malformation; trauma; surgical excision.

Anahtar Sözcükler: Arteriyovenöz malformasyon; travma; cerrahi eksizyon.

The vasculopathies may involve arteries, veins or lymphatic vessels, or a combination in the same patient in one or multiple localizations. Classifications are based mainly on the morphological structure of the lesions, cellular biology, hemodynamic features, and diagnostic evaluations. Based on a recent classification described by Mulliken, vascular anomalies are divided into two main areas, as hemangioma and other malformations.[1,2] Malformations may be with low-flow pattern, high-flow pattern and complex-combined syndromes. Surgical evaluation and indication vary with the type and abnormality of the situation.

idly growing and painful bulky lesion on the posterior left forearm admitted to the emergency department.

He described a stable mass lesion at the same localization presenting from his early childhood. The patient, who was a police officer, suffered a blunt trauma at the site of the mass lesion during an official criminal investigation. Following the blunt trauma, the mass size doubled in diameter in a few hours. Results of the physical examination were within normal limits excluding the growing pulsatile bulky mass lesion on the extensor side of the left forearm. There was no active bleeding. The lesion was sensitive and warm with palpation and measured 3x4 cm on observation (Fig. 1a). An emergent Doppler ultrasonography revealed normal compression response and normal diameters for the left arm veins. Artery diameters and blood flow patterns were in normal ranges. There was no evi-

CASE REPORT We report a case of progressively growing posttraumatic arteriovenous malformation on the left forearm. A 29-year-old male patient with a history of rap-

Department of 1Cardiovascular Surgery, 2Pathology, Erzurum Regional Training and Research Hospital, Erzurum, Turkey.

Erzurum Bölge Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, 2Patoloji Bölümü, Erzurum.

1

Correspondence (İletişim): Bilgehan Erkut, M.D. Erzurum Bölge Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, Erzurum, Turkey.

Tel: +90 - 442 - 232 57 55 e-mail (e-posta): bilgehanerkut@yahoo.com

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Arteriovenous malformation

(a)

(b)

Fig. 1. (a) Image of the dermal bulky lesion. (b) The preoperative ultrasonography image.

dence of intravascular thrombosis. On the forearm of the patient at the examined area posterolaterally, there was an arteriovenous malformation between the radial artery and cephalic vein measuring 4x5 cm (Fig. 1b).

There were no images of active extravascular leakage of blood from the arteriovenous malformation. All arterial pulses were detectable. Afterwards, the patient was operated under general anesthesia. Surgical skin incision was made over and along the lesion. Following the subcutaneous tissue dissection, surgical exposure reached the mass lesion of the arteriovenous malformation. The lesion was observed to be approximately 3x4x4 cm, immobile and adherent to surrounding tissue. Vascular structure arose from the radial artery distally and drained to the cephalic vein after a plexus of vessels. Total mass excision was achieved with multiple ligations of the collateral vascularities and careful dissection. The operation was carried out free of any major vascular or neurological injuries or complications. Closure of the anatomical layers was carried out safely. We observed no damage to adjacent vital structures, and the resection could be completed.

Early postoperative clinical follow-up was uneventful.

The patient was discharged from the hospital on postoperative day 5. A pathological investigation of the specimen from the excision material was described as arteriovenous malformation by the pathology department (Fig. 2).

DISCUSSION Vascular abnormalities are listed in two different groups according to Mulliken, as hemangioma and other malformations. Hemangioma is a congenital abnormality of endothelial hyperplasia with rapid cellular expression, which usually disappears following birth. These are the most common tumors of the neonatal period, known as birthmarks. Most of the cases, at a rate of 70% of lesions, vanish in seven years.[1-3] A distinctive diagnosis between hemangioma and vascular malformation is mandatory. The findings for hemangioma are: no presentation during the early days of birth, tendency to grow rapidly, female to male ratio of 4 to 1, accumulation of endothelial and mast cells dominantly, thrombocytopenia in severe cases like Cilt - Vol. 18 Say覺 - No. 4

Kasabach-Merritt syndrome, and measurable margins.[4,5] The group of other malformations including arteriovenous malformations usually exist at birth.

Malformations grow slowly. Their growth is usually triggered by trauma, sepsis or hormonal situations.

Histopathological features usually include normal endothelial cells, normal rate of mast cells and a thin layer of basal membrane.

Arteriovenous malformations tend to present a series of typical features, such as pulsation, trill, often murmurs, and angiographic proof of feeding artery or arteries.[6] In our case, the expanding lesion was sensitive to touch and pulsation with trill was observed.

A mild murmur was heard on auscultation. Surgery is not required in most cases. Classic surgical indications for a vascular arteriovenous malformation are described as ulcers resistant to medical therapy, extremity ischemia and congestive heart failure. Alternative treatment to surgery includes catheters or medical embolizations and laser administrations.[7,8] A post-traumatic case requires a rapid decision for surgery. Lee et al.[9] reported a series of 797 patients treated with combined embolotherapy, sclerotherapy and surgical procedures to manage arteriovenous mal-

Fig. 2. Histopathological investigations of the excision material.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org).

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formations. They reported their results as excellent, and there was no evidence of recurrence within 24 months. Four major complications occurred, including facial nerve palsy, pulmonary embolism, deep vein thrombosis, and massive necrosis of ear cartilage in the surgery group.

In conclusion, a trauma may be the cause of a vascular emergency especially for a case involving an arteriovenous malformation. Surgical resection may be difficult, with the potential for exsanguinations, hemorrhage and damage to surrounding structures.

Despite these factors, we strongly advocate that, in emergency cases with active bleeding or acute ischemia, a Doppler ultrasonography is sufficient for the decision to operate.

REFERENCES 1. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:41222.

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2. Mulliken JB. Cutaneus vascular anomalies. Semin Vasc Surg 1993;6:204-18.

3. Qing Y, Cen Y, Xu X, Duan W, Liu Y. Surgical treatment of hemangioma and vascular malformation in body surface.

[Article in Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23:325-7. [Abtract] 4. Low DW. Hemangiomas and vascular malformations. Semin Pediatr Surg 1994;3:40-61.

5. Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol 1997;13:375-423.

6. Coffin CM, Dehner LP, O’Shea PA. Vascular tumors. In: Pediatric soft tissue tumors: a clinical, pathological, and therapeutic approach. Baltimore, MD: Lippincott, Williams & Wilkins; 1997. p. 40-79.

7. Lee BB, Kim DI, Huh S, Kim HH, Choo IW, Byun HS, et al.

New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg 2001;33:764-72.

8. Duran E. Kalp ve damar cerrahisi. İstanbul: Çapa Tıp Kitap Evi; 2004.

9. Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a multidisciplinary approach. J Vasc Surg 2004;39:590-600.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):347-350

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.66900

Cerebral infarction caused by traumatic carotid artery dissection Travmatik karotid arter diseksiyonuna bağlı serebral enfarktüs Ayşegül BAYIR,1 Demet AYDOĞDU KIREŞİ,2 Ali SÖYLEMEZ,3 Osman DEMİRCİ4

Traumatic carotid artery dissection, if not diagnosed and treated early, is a serious problem with permanent neurological deficit and a high mortality rate of up to 40%. We present a case with delayed diagnosis of traumatic carotid artery dissection in a 21-year-old female. While there were no ischemic infarct findings on the admission cerebral computerized tomography (CT), such findings were observed on two cerebral CTs taken because of the left hemiplegia noticed seven days later when the patient regained consciousness. The patient was referred to our emergency service, and definitive diagnosis was achieved with arterial Doppler ultrasonography, cerebral magnetic resonance imaging (MRI), diffusion MRI, and MR angiography. We did not consider invasive treatment since the neurological damage was permanent and dissection grade was IV according to angiography findings. The case was discharged within a week and physiotherapy was advised. Despite the advances in diagnostic methods, diagnosis of traumatic carotid artery dissection is still missed or delayed, as in the case presented here. Early diagnosis can ameliorate permanent neurological damage or even prevent it.

However, the vital factors for early diagnosis are the obtained anamnesis leading to appropriate radiological examinations, detailed physical examination and high clinical suspicion.

Travmatik karotid arter diseksiyonu eğer erken tanı konulup tedavi edilmezse kalıcı nörolojik defisit ve %40’lara varan ölüm oranı yaratabilen ciddi bir sorundur. Bu yazıda, travmatik karotid arter diseksiyonu tanısı geç dönemde konan 21 yaşında kadın hasta sunuldu. Kabulde çekilen beyin bilgisayarlı tomografisinde (BT) iskemik enfarkt bulguları yok iken, bilinci açıldıktan sonra yedinci gün sol hemiplejisi fark edildiğinde çekilen ikinci beyin BT’sinde enfarktüs bulguları saptandı. Hasta acil servise kabul edildi. Kesin tanı, arteriyel Doppler ultrasonografi, serebral manyetik rezonans görüntüleme (MRG), difüzyon MRG ve MR anjiyografi ile konuldu. Hastada kalıcı nörolojik hasar geliştiği ve anjiyografi bulgularına göre evre IV olduğu için invaziv tedavi düşünülmedi. Hasta fizyoterapi tavsiye edilerek bir hafta içinde taburcu edildi. Tanısal yöntemlerdeki gelişmelere rağmen travmatik karotid arter diseksiyonunun tanısı bu olguda olduğu gibi halen atlanmakta veya gecikmektedir. Erken tanı kalıcı nörolojik hasarı önleyebilir ya da hafifletebilir. Bununla birlikte erken tanı için en önemli faktörler uygun radyolojik incelemeyi yönlendirecek anamnez, ayrıntılı fiziksel inceleme ve yüksek klinik şüphedir.

Key Words: Doppler ultrasonography; internal carotid artery; magnetic resonance angiography; traumatic dissection.

Anahtar Sözcükler: Doppler ultrasonografi; internal karotid arter; manyetik rezonans anjiyografi; travmatik diseksiyon.

The incidence of internal carotid artery dissection (ICAD) caused by blunt trauma is unknown, since the onset of symptoms and signs are frequently delayed,[1] but it has been reported to be 0.08%.[2] Traumatic ICAD is often accompanied by thrombosis, resulting

in permanent neurological deficits and carrying a mortality rate of up to 40%.[3,4] In this case report, we present a patient whose ICAD was diagnosed one week after being involved in a motorcycle accident and hospitalized at an outlying hospital.

1 Department of Emergency Medicine, Selcuk University Selcuklu Faculty of Medicine, Konya; 2Department of Radiology, Selcuk University Meram Faculty of Medicine, Konya; 3Department of Neurology, Suleyman Demirel University Faculty of Medicine, Isparta; 4 Department of Emergency Medicine, Siirt State Hospital, Siirt, Turkey.

Selçuk Üniversitesi Selçuklu Tıp Fakültesi, Acil Tıp Anabilim Dalı, Konya; 2Selçuk Üniversitesi Meram Tıp Fakültesi, Radyoloji Anabilim Dalı, Konya; 3Süleyman Demirel Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Isparta; 4Siirt Devlet Hastanesi Acil Servisi, Siirt.

1

Correspondence (İletişim): Ayşegül Bayır, M.D. Selçuk Üniversitesi Selçuklu Tıp Fakültesi, Acil Tıp Anabilim Dalı, Konya, Turkey.

Tel: +90 - 332 - 241 50 00 e-mail (e-posta): aysegulbayir@hotmail.com

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CASE REPORT A 21-year-old female motorcycle passenger was involved in a motor vehicle accident and was brought to the emergency service of a rural government hospital.

She was comatose on presentation, and was found to have left radius-ulna fractures on plain films and cerebral edema on non-contrast head computerized tomography (CT) scan. In the neurosurgical intensive care unit (ICU), as she regained consciousness over the next few days, weakness of her left arm and leg was noted. A repeat head CT showed a hypodense infarct in the right frontoparietal and basal ganglion areas (Fig. 1a). With a diagnosis of ‘acute embolic stroke’, she was transferred to our tertiary care university hospital emergency department.

Upon arrival, she was conscious and cooperative with complaints of left hemiparesis. Her vital signs were blood pressure (BP) 120/70 mmHg, pulse rate 72/ min, respiratory rate 18/min and temperature 36.8°C. Her pupillary exam was normal and her Glasgow Coma Score was 13. Motor strength was 1/5 in the left upper extremity and 1/5 in the lower extremity. Her left Babinski reflex was positive. Given her clinical picture of posttraumatic stroke, carotid artery injury was suspected.

Diffusion magnetic resonance imaging (MRI) of the brain demonstrated decreased diffusion in the ADC map area, compatible with a large acute infarct and mainly diffusion in the frontal-temporal and parietal zone of the right cerebral hemisphere (Fig. 1b).

On T2 axial MR images, loss of flow in the right ICA was observed at the level of the cavernous sinus on the right. Signal alterations consistent with acute infarct were seen in the right frontal, temporal and parietal lobes, including the basal ganglia. The right carotid superior was filled to the Circle of Willis, and subacute hematoma and right ICAD at the level of the inferior pars petrosa were seen (Figs. 1c, d). On MR angiography, no flow of contrast was seen in the right ICA and carotid bulbus superior, or in the middle portion of the right ICA (Figs. 1e, f). Carotid Doppler ultrasonography showed dissection of the right ICA and a thrombus causing total occlusion beginning at the bifurcation (Figs. 1g, h).

The patient was hospitalized for treatment and follow-up. Since permanent neurological damage had developed and the infarct area was large, anticoagulation was not performed due to concerns that such treatment might trigger hemorrhage in the ischemic infarct area. The patient was discharged with follow-up in the neurology and physical medicine and rehabilitation clinics. The patient’s neurological symptoms and signs (permanent left hemiplegia) were unchanged during three months of follow-up.

348

DISCUSSION Traumatic ICAD is a rare and serious cause of embolic stroke in the younger age group. The basic pathophysiological mechanism is stretching of the artery through rotation-hyperextension or distractionflexion.[5] While only 10% of cases have an immediate onset of symptoms, in most patients, clinical signs of the dissection occur within the first 24 hours following the traumatic event. No symptoms occur within the first 24 hours after trauma in 35% of cases. In patients with traumatic ICAD who exhibit neurologic deficits, brain CT performed within the first 24 hours is usually non-diagnostic.[6] Traumatic ICAD is usually suspected and diagnosed when a neurological deficit develops unexpectedly after trauma, evolving clinically into a ‘stroke’ in 80% of the cases during the first week after symptom onset.[1] In addition to a detailed history and careful physical examination, duplex carotid ultrasound, CT, CT angiography, MRI, MR angiography, and conventional angiography are imaging studies that can be performed to diagnose traumatic ICAD.[7,8] The present case was referred to us with a diagnosis of acute embolic stroke although she had no signs of ischemia on her CT performed at the first hospital.

A comprehensive neurologic exam could not be performed secondary to her depressed level of consciousness. In light of the patient’s young age and history of trauma, we suspected traumatic ICAD when we viewed her CT and found corresponding neurologic deficits. To make the definitive diagnosis in our patient, we performed brain MRI, diffusion MRI, carotid Doppler ultrasound, and MR angiography.

Traumatic CAD is divided into five grades according to angiographic findings, and therapy is undertaken accordingly: Grade I: with ≤25% narrowing of the lumen, luminal disruption or dissection; Grade II: >25% narrowing of the lumen, together with dissection or intramural hematoma, intraluminal thrombus or split flap, Grade III: pseudoaneurysm, Grade IV: complete occlusion, and Grade V: signs of transection with contrast extravasation.[9] Grade I traumatic ICAD is treated conservatively with anticoagulants, as only 7% will progress to a higher grade. However, 70% of Grade II dissections rapidly progress to pseudoaneurysm formation and occlusion, and thus require aggressive surgical treatment.[5] With the latest improvements in endovascular stenting, successful results have been obtained in Grade I and Grade II ICADs.[10] Grade IV dissections are usually complicated by cerebral embolism and stroke. Recanalization procedures in Grade IV traumatic ICAD are associated with a high rate of complications, thus observation and/or anticoagulation is advised. Grade Temmuz - July 2012

Cerebral infarction caused by traumatic carotid artery dissection

V ICAD requires urgent surgical ligation and hemorrhage control.[5]

that the dissected superior carotid artery was filled with Willis Polygon.

Our patient had a Grade IV ICAD, as diagnosed by MR angiography. The delay in diagnosis at the outlying hospital may have led to the development of permanent neurologic deficits. MR angiography revealed

Traumatic ICAD is a rare occurrence and its diagnosis can easily be missed or delayed despite advances in imaging procedures. Obtaining a detailed history and performing a comprehensive examination

(a)

(b)

(c)

(d)

(e)

(f)

Fig. 1. (a) Non-contrast CT performed at 7 days in our 23-yearold motorcycle accident victim.

A hypodense lesion in the right frontoparietal and basal ganglion area, suggestive of ischemia, can be seen. (b, c) Diffusionweighted MRI in the right frontotemporal and parietal lobes, suggesting an acute infarct in the ADC map. (d) T2 contrast MRI showing loss of the flow of the (h) (g) internal carotid artery at the level of the cavernous sinus on the right. (e, f) Contrast MR angiogram showing cut-off of flow in the internal carotid artery at the level of the carotid bulb. Flow is also absent in the right middle cerebral artery. Longitudinal (g) and transverse (h) Doppler ultrasound images of the right internal carotid artery just superior to the carotid bulb showing a linear echogenic band (white arrow) in the lumen, compatible with dissection.

Cilt - Vol. 18 Say覺 - No. 4

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will lead the clinician to suspect ICAD in the setting of post-traumatic unilateral neurologic abnormalities with a normal or near-normal non-contrast CT. Carotid Doppler is an easily performed study that can rule out the presence of ICAD in suspicious cases. Advances in CT and MR angiography techniques and machines have made it possible to establish a rapid and accurate diagnosis. After an accurate diagnosis has been made, immediate treatment to reduce complications and optimize outcome should be performed.

REFERENCES 1. Blanco PampĂ­n J, Morte Tamayo N, Hinojal Fonseca R, Payne-James JJ, Jerreat P. Delayed presentation of carotid dissection, cerebral ischemia, and infarction following blunt trauma: two cases. J Clin Forensic Med 2002;9:136-40.

2. Davis JW, Holbrook TL, Hoyt DB, Mackersie RC, Field TO Jr, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma 1990;30:1514-7.

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3. Hughes KM, Collier B, Greene KA, Kurek S. Traumatic carotid artery dissection: a significant incidental finding. Am Surg 2000;66:1023-7.

4. Martin RF, Eldrup JJ, Clark DE, Bredenberg CE. Blunt trauma to the carotid arteries. J Vasc Surg 1991;14:789-93.

5. Yang ST, Huang YC, Chuang CC, Hsu PW. Traumatic internal carotid artery dissection. J Clin Neurosci 2006;13:123-8.

6. Sasser PL, Stein MA, Johnson JK. Blunt carotid artery trauma: diagnosis and management. Contemp Surg 1992;41:559.

7. Liu AY, Paulsen RD, Marcellus ML, Steinberg GK, Marks MP. Long-term outcomes after carotid stent placement treatment of carotid artery dissection. Neurosurgery 1999;45:1368-74.

8. Zetterling M, CarlstrĂśm C, Konrad P. Internal carotid artery dissection. Acta Neurol Scand 2000;101:1-7.

9. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 1999;47:845-53.

10. Pagnotta P, Briguori C, Saluzzo CM, Presbitero P. Endovascular treatment of traumatic bilateral internal carotid artery dissection. J Invasive Cardiol 2009;21:E6-8.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):351-354

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.06887

Ileus due to Meckel’s diverticulum: case reports Meckel divertikülüne bağlı ileus: Olgu sunumları Selim SÖZEN, Ömer TOPUZ, Mustafa TÜKENMEZ, Ömer Fazıl BİLGİN, Yunus DÖNDER

Meckel’s diverticulum is the most common congenital anomaly of the small intestine, with an estimated incidence of approximately 1-3% in the general population. Intestinal obstruction is the most common complication in adult patients. Since accurate diagnosis before the operation is difficult, decision for surgery is delayed, and serious problems may be encountered. Here in, we present the diagnosis and management of our patients with intestinal obstruction due to Meckel’s diverticulum.

Key Words: Ileus; intestinal obstruction; Meckel’s diverticulum.

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 2-3% of the general population.[1,2] In the majority of patients, Meckel’s diverticulum is asymptomatic.[3,4] Only 16% of Meckel’s diverticula give rise to symptoms.[5] The most common presentation in adults is intestinal obstruction. The most common means of obstruction is intussusception with the Meckel’s diverticulum being the lead point. Other causes of obstruction include volvulus around fibrous bands adherent to the umbilicus, Littre’s hernia and diverticular strictures, and loop formations of Meckel’s diverticulum.[6,7] This report summarizes three cases and presents a brief review of the literature.

Meckel divertikülü ince bağırsağın en sık rastlanan doğumsal anomalisi olup genel nüfusta %1-3 oranında görülür. Erişkinlerde en sık görülen komplikasyonu bağırsak tıkanıklığıdır. Ameliyat öncesi tanının sıklıkla mümkün olmaması ve ameliyatta gecikilmesi ciddi sorunlara neden olabilir. Bu yazıda, Meckel divertikülü nedeniyle bağırsak tıkanıklığı olan hastaların tanısı ve tedavi yönetimi sunuldu.

Anahtar Sözcükler: İleus; bağırsak tıkanıklığı; Meckel divertikülü.

that suggested intestinal obstruction (Fig. 1a). In addition to these important findings, abdominal tenderness especially in the right lower quadrant and a palpable mass were present. The patient was operated with the diagnosis of plastron appendicitis. The abdomen was entered by McBurney incision. In the exploration, the appendix was seen to be normal and there was an ileocecal intussusception due to Meckel’s diverticulum.

The intussusception was reduced manually (Figs. 1b, c). Meckel’s diverticulum was resected in the form of wedge resection. The postoperative period was uneventful and the patient was discharged on postoperative day 4.

CASES REPORTS Case 1– A 65-year-old male patient presented with abdominal pain, anorexia, nausea, vomiting, and abdominal bloating. On his physical examination, there were abdominal tenderness, rebound and increased bowel sounds in all quadrants. Laboratory findings, except leukocytosis (11,000 mm3), were normal. Abdominal radiograph was obtained first in this patient with acute symptoms, which revealed air-fluid levels

Case 2– A 42-year-old male patient with no previous abdominal surgery, who experienced severe abdominal pain and vomiting in the course of one day, was admitted to the emergency service of our hospital. There was no significant medical history. His body temperature was 37.6°C and vital signs were stable. His abdomen was very tender and distended, and bowel sounds were hyperactive. There was no palpable mass. Laboratory findings showed a white blood cell count (WBC) of 9,600 mm3, hemoglobin 12.3 g/dl, and platelets 280,000. All other studies, in-

Kayseri Training and Research Hospital, Kayseri, Turkey.

Kayseri Eğitim ve Araştırma Hastanesi, Kayseri.

Correspondence (İletişim): Selim Sözen, M.D. Yurt Mah., 71335 Sok., No: 13/19, İrfan Altaş Aptl, Çukurova, Adana, Turkey..

Tel: +90 - 352 - 336 88 84 e-mail (e-posta): selimsozen63@yahoo.com

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(a)

(b)

(c)

Fig. 1. (a) Abdominal radiograph revealed the presence of distended jejunal and ileal bowel loops. (b) Ileocecal intussusception. (c) Ileocecal intussusception due to Meckel’s diverticulum.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

cluding electrolytes and urinalysis, were within normal limits. There were air-fluid levels on the abdominal radiograph. Computed tomography (CT) showing marked dilatation of the small intestine suggested the obstruction was near the ileocecal valve (Fig. 2a). He was diagnosed with mechanical intestinal obstruction, and nasogastric decompression was performed. Emergency exploratory laparotomy was performed under general anesthesia. The distal part of the ileum was markedly dilated and formed a loop, clasped at its base by a loop-like structure located 70 cm proximal to the ileocecal valve (Fig. 2b). After separating the structure from the mesentery, it proved to be Meckel’s diverticulum, the end of which was adhered to the corresponding dorsal mesentery. The ileal loop was released from the diverticulum. The necrotic segment and Meckel’s diverticulum were resected and functional end-to-end anastomosis of the bowel was completed. The diverticulum was confirmed as Meckel’s diverticulum by histological examination. The postoperative period was uneventful, and the patient was discharged on postoperative day 10.

Case 3– A 19-year-old man with no previous abdominal surgery presented with a 24-hour history of

(a)

abdominal pain, nausea and vomiting. There was no significant medical history. His body temperature was 36.5°C and the vital signs were stable. His abdomen was very tender and distended. Bowel sounds were hypoactive. The rectal exam showed an empty vault.

No masses were palpable. WBC count was 9.0 x 103 /mm3 with 94.5% neutrophils, hemoglobin was 9.0 g/dl and hematocrit was 31.3%; liver and pancreatic enzymes were not elevated. An abdominal radiograph showed air-fluid levels of the small intestine, suggesting a complete obstruction of the small intestine. Abdominal CT showed marked dilatation of the stomach and small intestine and suggested the obstruction was near the ileocecal valve. The patient was diagnosed as having intestinal obstruction. Emergent laparotomy showed a Meckel’s diverticulum that had formed a band around a portion of the small bowel causing it to twist upon itself with subsequent necrosis. Resection of the Meckel’s diverticulum with necrotic segment of the intestine and functional end-to-end anastomosis were performed. The diverticulum was confirmed as Meckel’s diverticulum by histological examination.

The patient recovered without any complications and was discharged on the fifth day of hospitalization.

(b)

Fig. 2. (a) Computed tomography (CT) showing marked dilatation of the small intestine suggested the obstruction was near the end of the ileum. (b) Meckel’s diverticulum and necrotic ileal segment. (The distal part of the ileum was markedly dilated and formed a loop, clasped at its base by a loop-like structure located 70 cm proximal to the end of the ileum.)

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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Ileus due to Meckel’s diverticulum

DISCUSSION Meckel’s diverticulum was first described by Fabricius Hildanus in 1598. The name derives from the German anatomist Johann Friedrich Meckel, who described the embryological and pathological features in 1809.[8] Meckel’s diverticulum is a common abnormality of the gastrointestinal tract, and is a remnant of the omphalomesenteric duct that is assumed to disappear at birth. The incidence of Meckel’s diverticulum is about 1-3%; most cases are asymptomatic and are found during laparotomy or autopsy.[1] Meckel’s diverticulum is the most common end result of the spectrum of omphalomesenteric duct anomalies, which also include umbilico-ileal fistula, omphalomesenteric duct sinus, omphalomesenteric duct cyst, fibrous connection of the ileum to the umbilicus, and Meckel’s diverticulum, with the latter being the most common (98% of cases) of the omphalomesenteric duct anomalies. The diverticulum is usually found within 100 cm of the ileocecal valve on the antimesenteric border of the ileum.[1,9] The complications of Meckel’s diverticulum are hemorrhage, intestinal obstruction and diverticulitis. Intestinal obstruction is the second most common complication of Meckel’s diverticulum.[2,10] There are many mechanisms for small intestinal obstruction from a Meckel’s diverticulum. It may produce obstruction by diverticular inversion causing luminal obstruction or leading to an intussusception, volvulus from persistent attachment to the umbilicus, adhesions, congenital meso-diverticular bands, diverticulitis, foreign body impaction, inclusion of the diverticulum into a hernia, neoplasm, Meckel’s diverticulum lithiasis, or formation of a loop.[5,6] A band extending between the diverticulum and the base of the mesentery can also form a loop in which a part of the ileum may get stuck, causing obstruction.[7] Other mechanisms involve rare causes of obstruction like tumors (lipomas, carcinoid tumors and others), impacted meconium in neonates causing inflammatory adhesions of Meckel’s diverticulum to surrounding structures leading to volvulus, cecal volvulus around the band extending from Meckel’s diverticulum to the umbilicus, gallstone ileus, and obstruction secondary to phytobezoar formation in the Meckel’s diverticulum.[10] Complications occur more frequently in males.

Most patients who develop symptoms are younger than 10 years. While bleeding is the most common complication in children, intestinal obstruction seems to be the most common complication in the adult age group.[2,6] The important aspect of our cases was that all patients were adults.

Abdominal radiograph may reveal dilated bowel loops and multiple air-fluid levels. Although of limited value, sonography has been used for the investigation of Meckel’s diverticulum. High-resolution Cilt - Vol. 18 Sayı - No. 4

sonography usually shows a fluid-filled structure in the right lower quadrant having the appearance of a blind-ending, thick-walled loop of bowel. CT has 9094% sensitivity and 96-100% specificity for the diagnosis of small bowel obstruction and a 40-73% positive predictive value for predicting the cause of the obstruction.[11] Therefore, it is difficult to use CT to accurately identify a Meckel’s diverticulum as the cause of intestinal obstruction.[4] Abdominal CT is used for complicated cases such as intussusceptions. CT can help to confirm the presence of intussusception and to distinguish between lead point and non-lead point intussusceptions.

Correct diagnosis of Meckel’s diverticulum before an operation is often difficult because a complicated Meckel’s diverticulum simulates many other abdominal pathologies. The patient typically presents with the features of small bowel obstruction like absolute constipation, spasmodic abdominal pain, vomiting (which may be bilious), and abdominal distention.

The optimal treatment of adult intussusception is not agreed on universally. All authors agree that laparotomy is mandatory, in view of the likelihood of identifying a pathologic lesion. Most authors recommend a segmental small bowel resection of the invaginated part as surgical treatment of the intussusception.[12] In case of intussusception due to Meckel’s diverticulum, the surgical treatment choice should be resection of the small bowel including the Meckel’s diverticulum. In the first case, the Meckel’s diverticulum was resected together with a small segment of the ileum, as in the literature. The operation should always include resection of the diverticulum or a segment of the bowel affected by the pathology.[13] In conclusion, intestinal obstruction is the most common complication of Meckel’s diverticulum.[1,5] A preoperative diagnosis was not possible in view of the non-specific nature of the clinical and radiological findings. Intestinal obstruction due to Meckel’s diverticulum might cause ileal strangulation because of acute obstruction. The clinician should be aware of this possibility and try to reach the diagnosis more quickly to avoid unnecessary bowel resection.

REFERENCES 1. Turgeon DK, Barnett JL. Meckel’s diverticulum. Am J Gastroenterol 1990;85:777-81.

2. Kaya O, Moran M, Özdemir F, Çetinkünar S. A rare cause of intestinal obstruction: Meckel’s diverticulitis. Turk J Med Sci 2008;38:277-9.

3. Arnold JF, Pellicane JV. Meckel’s diverticulum: a ten-year experience. Am Surg 1997;63:354-5.

4. Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics 2004;24:565-87.

5. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. 353

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6.

7.

8.

9.

Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg 2005;241:529-33.

Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D. Complications of Meckel’s diverticula in adults.

Can J Surg 2006;49:353-7.

Tomikawa M, Taomoto J, Saku M, Takeshita M, Yoshida K, Sugimachi K. A loop formation of Meckel’s diverticulum: a case with obstruction of the ileum. Ulus Travma Acil Cerrahi Derg 2003;9:134-6.

Raymond P. Adjunctive procedure in intestinal surgery. Mastery of Surgery. 5th ed. 2007. p. 1392-3.

Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL.

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Meckel’s diverticulum. J Am Coll Surg 2001;192:658-62.

10. Sharma RK, Jain VK. Emergency surgery for Meckel’s diverticulum. World J Emerg Surg 2008;3:27.

11. Nipper ML, Jacobson LK. Expanded applications of CT. Helical scanning in five common acute conditions. Postgrad Med 2001;109:68-70, 73-7.

12. Van Hee R, Brewaeys P, Buyssens N. Ileal intussusception due to invagination of Meckel’s diverticulum. Acta Chir Belg 1992;92:55-9.

13. D’Souza CR, Kilam S, Prokopishyn H. Axial volvulus of the small bowel caused by Meckel’s diverticulum. Surgery 1993;114:984-7.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (4):355-357

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.04317

Bilateral asymmetric traumatic hip dislocation with bilateral acetabular fracture: case report İki taraflı asimetrik travmatik kalça çıkığı ve iki taraflı asetabulum kırığı: Olgu sunumu Ercan OLCAY,1 Oktay ADANIR,2 Erdem ÖZDEN,1 # Alican BARIŞ1 ¶

Bilateral traumatic hip dislocation is a very rare condition.

Simultaneous anterior and posterior traumatic dislocation of both hips is even more unusual. A case report of a bilateral asymmetrical hip joint dislocation with bilateral acetabular fracture in a 28-year-old man is presented.

İki taraflı travmatik kalça çıkığı nadir görülen bir durumdur. Her iki kalçanın aynı zamanda öne ve arkaya çıkığı daha da nadirdir. Bu yazıda, 28 yaşındaki bir erkek hastada iki taraflı asimetrik kalça çıkığı ile birlikte görülen iki taraflı asetabulum kırığı sunuldu.

Key Words: Acetabular fracture; bilateral traumatic hip dislocation.

Anahtar Sözcükler: Asetabulum kırığı; travmatik kalça çıkığı.

Traumatic hip dislocation is a true orthopedic emergency, which generally occurs as a result of highenergy trauma and can cause serious complications. Its frequency has increased with technological advances, and traumatic hip dislocations currently represent 5% of all dislocations.[1] In a review of the literature to date, we found totally 58 reported cases of bilateral traumatic hip dislocation.[2,3] Only four cases of asymmetric hip dislocations with unilateral acetabular fracture have been reported to date.[3-6] A single case of asymmetric hip dislocation with bilateral acetabular fracture has been reported.[2]

occurred. His vital signs (arterial blood pressure, peripheral pulse rate and respiratory rate) were normal.

The patient complained of severe pain in both hips.

On the physical examination, he had a 5 cm wound at the occipital region and multiple dermal abrasions on his face and extremities. On examination of the extremities, the left limb had an adduction, flexion and internal rotation deformity and the right limb had an abduction, flexion and external rotation deformity.

There was no neurovascular deficit. In the radiological evaluation, anterior dislocation of the right hip and anterior rim fracture and posterior dislocation of the left hip and posterior rim fracture were determined. Both anterior and posterior dislocations were evaluated as type 1 according to the Thompson-Epstein classification (Fig. 1).[7,8]

In this article, a 28-year-old male with right anterior and left posterior hip dislocations and right acetabular anterior and left acetabular posterior rim fractures is presented.

CASE REPORT A 28-year-old male patient was admitted to our emergency department approximately one hour after being involved in a motor vehicle accident. He was previously healthy and had no prior history of pelvic trauma, hip abnormality or ligamentous laxity. On arrival, he was conscious (Glasgow coma score 15), but did not remember the time period in which the accident 1 Department of Orthopaedics and Traumatology, Kafkas University Faculty of Medicine, Kars; 2Department of Orthopaedics and Traumatology Bagcılar Training and Research Hospital, Istanbul, Turkey.

Both hips were reduced under general anesthesia approximately 90 minutes after trauma using the Bigelow method, and then stability of the hips was evaluated. Skeletal traction was applied on both distal femurs. The wound at the occipital region was sutured.

Before the patient was hospitalized in the ward, postreduction radiographs and computerized tomographic (CT) views were obtained (Fig. 2). Post-reduction views revealed congruent reduction of both hips and Kafkas Üniveritesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, Kars; 2Bağcılar Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul.

1

Current affiliation: #Baltalimanı Training and Research Hospital, İstanbul; ¶İstanbul Training and Research Hospital, İstanbul.

Correspondence (İletişim): Ercan Olcay, M.D. Vatan Cad., Emlak Bank Evleri, C-1, D: 7, Fatih 34090 İstanbul, Turkey.

Tel: +90 - 212 - 631 49 16 e-mail (e-posta): ercanolcay@superonline.com

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Fig. 1. The initial radiograph.

Fig. 2. The post-reduction CT view.

associated bilateral non-displaced acetabulum fracture. The patient was hospitalized in the ward and consultations were obtained from the general surgery, chest surgery, neurosurgery, and urology departments.

Appropriate medication for the prevention of pain, infection, deep vein thrombosis, and heterotopic ossification was started.

The hip joint is a rather stable articulation with its anatomical structure, strong ligaments and muscles.

[9,10] Therefore, dislocations of the hip joint can only be caused by high-energy trauma. Nowadays, frequency of hip dislocation is increasing because of technological advances and the changing lifestyle of the population.

On the second day, strengthening exercises for the quadriceps were begun. In the third week, skeletal tractions were removed and the patient was permitted to sit in the bed. In addition, passive exercises for the hip and active and passive exercises for the knees were started. The patient was permitted to walk with complete weight-bearing from the fourth month. He was followed for 32 months, with quarterly visits in the first year and at six-month intervals thereafter. The patientâ&#x20AC;&#x2122;s clinical and radiological findings were evaluated as excellent according to Thompson-Epstein clinical and radiological criteria. At the last visit, no sign of avascular necrosis or osteoarthritis was found on the hip radiograph or magnetic resonance imaging (MRI) (Figs. 3, 4).

It has been reported that traumatic hip dislocations represent 5% of all dislocations.[1] In the English literature, there have been a total of 58 cases with bilateral hip dislocation.[2,3] Those are cases with pure dislocation or with accompanying injuries like sciatic nerve injury, femoral fracture, patellar fracture, and acetabulum and femoral head fracture.[11,12] Only four cases with asymmetric hip dislocation and unilateral acetabular fracture have been reported to date.[3-6] Furthermore, a single case with asymmetric hip dislocation and bilateral acetabular fracture has been reported.[2]

DISCUSSION

Fig. 3. The follow-up radiograph at the 32nd month.

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The hip position during trauma defines the direction of dislocation. According to the opinion generally accepted, if the leg is adducted-flexed and internally rotated, posterior dislocation occurs, whereas if the leg is abducted-flexed and externally rotated, anterior dis-

Fig. 4. The follow-up MRI at the 32nd month.

Temmuz - July 2012

Bilateral asymmetric traumatic hip dislocation with bilateral acetabular fracture

location occurs.[13-15] For traumatic hip dislocations, the most important prognosing factor is the time period prior to the reduction.[13,16,17] Many authors emphasize that the reduction should be performed within the first six hours.[9,1618] The rates of avascular necrosis for the cases with early and delayed reduction were reported as 6-27% and 48%, respectively.[13,16,18] In addition, the force of trauma and recurrent maneuvers for reduction increase the risk of avascular necrosis.[19] It has been reported that the risk of coxarthrosis is proportionally increased with the severity of the trauma. This rate has ranged from 17-48.8% proportionally related to the follow-up period.[9] Another prognosing factor is the direction of dislocation. While the prognosis for central dislocations is the worst, it is best for anterior dislocations.

Associated acetabular and femoral head fractures also worsen the prognosis.[9,10,13,17-19] In addition, in hip dislocation, sciatic nerve injury can occur at a rate of 7-19%.[5,20] Other potential complications are heterotopic ossification, deep venous thrombosis and limitation of hip motion.

In hip dislocation, weight-bearing after reduction is controversial. It has been emphasized that traction is unnecessary if the hip joint is stable on post-reduction examination.[18,19] Though there are publications reporting better results with early mobilization,[10,16] there are also publications that declare that delayed weight-bearing does not alter the prognosis or the risk of avascular necrosis.[17] In the follow-up, quarterly radiological monitoring is necessary in the course of 18 months.[21] Postreduction CT scan is recommended to determine intra-articular free fragments, reduction and associated femoral head and acetabular fractures; however, the most efficient and harmless method for diagnosis and follow-up of avascular necrosis is MRI.[22] There are no statistical data available in the literature about complication rates of bilateral dislocations because of the insufficient number of the cases, but it is obvious that complications can occur more often with bilateral than unilateral dislocations. Thus, more careful attention should be given to these cases.

In conclusion, traumatic hip dislocation is a true orthopedic emergency. Proper diagnosis, early closed or open reduction, and evaluation of the reduction with CT are important for a good outcome.

REFERENCES 1. Altay M, Yağmurlu F, Heybeli M, Muratli HH, Tabak Y, Biçimoğlu A. Simultaneous asymmetric bilateral traumatic hip dislocation: a case report. [Article in Turkish] Acta

Cilt - Vol. 18 Sayı - No. 4

Orthop Traumatol Turc 2003;37:182-6.

2. Sahin O, Ozturk C, Dereboy F, Karaeminogullari O. Asymmetrical bilateral traumatic hip dislocation in an adult with bilateral acetabular fracture. Arch Orthop Trauma Surg 2007;127:643-6.

3. Pascarella R, Maresca A, Cappuccio M, Reggiani LM, Boriani S. Asymmetrical bilateral traumatic fracture dislocation of the hip: a report of two cases. Chir Organi Mov 2008;92:109-11.

4. Kaleli T, Alyüz N. Bilateral traumatic dislocation of the hip: simultaneously one hip anterior and the other posterior. Arch Orthop Trauma Surg 1998;117:479-80.

5. Shukla PC, Cooke SE, Pollack CV Jr, Kolb JC. Simultaneous asymmetric bilateral traumatic hip dislocation. Ann Emerg Med 1993;22:1768-71.

6. Martínez AA, Gracia F, Rodrigo J. Asymmetrical bilateral traumatic hip dislocation with ipsilateral acetabular fracture.

J Orthop Sci 2000;5:307-9.

7. Epstein HC. Traumatic dislocations of the hip. Clin Orthop Relat Res 1973;92:116-42.

8. Thompson VP, Epstein HC. Traumatic dislocation of the hip; a survey of two hundred and four cases covering a period of twenty-one years. J Bone Joint Surg [Am] 1951;33A(3):746-78.

9. Yang RS, Tsuang YH, Hang YS, Liu TK. Traumatic dislocation of the hip. Clin Orthop Relat Res 1991;(265):218-27.

10. Schlickewei W, Elsässer B, Mullaji AB, Kuner EH. Hip dislocation without fracture: traction or mobilization after reduction? Injury 1993;24:27-31.

11. Maqsood M, Walker AP. Asymmetrical bilateral traumatic hip dislocation with ipsilateral fracture of the femoral shaft.

Injury 1996;27:521-2.

12. Toms AD, Williams S, White SH. Obturator dislocation of the hip. J Bone Joint Surg [Br] 2001;83:113-5.

13. Goddard NJ. Classification of traumatic hip dislocation. Clin Orthop Relat Res 2000;(377):11-4.

14. Phillips AM, Konchwalla A. The pathologic features and mechanism of traumatic dislocation of the hip. Clin Orthop Relat Res 2000;(377):7-10.

15. Brooks RA, Ribbans WJ. Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop Relat Res 2000;(377):15-23.

16. Dreinhöfer KE, Schwarzkopf SR, Haas NP, Tscherne H. Isolated traumatic dislocation of the hip. Long-term results in 50 patients. J Bone Joint Surg [Br] 1994;76:6-12.

17. Rodríguez-Merchán EC. Osteonecrosis of the femoral head after traumatic hip dislocation in the adult. Clin Orthop Relat Res 2000;(377):68-77.

18. Alonso JE, Volgas DA, Giordano V, Stannard JP. A review of the treatment of hip dislocations associated with acetabular fractures. Clin Orthop Relat Res 2000;(377):32-43.

19. Yang EC, Cornwall R. Initial treatment of traumatic hip dislocations in the adult. Clin Orthop Relat Res 2000;(377):2431.

20. Brav CEA. Traumatic dislocation of the hip. J Bone Joint Surg [Am] 1962;44:1115-1134 21. Dudkiewicz I, Salai M, Horowitz S, Chechik A. Bilateral asymmetric traumatic dislocation of the hip joints. J Trauma 2000;49:336-8.

22. Mitchell MD, Kundel HL, Steinberg ME, Kressel HY, Alavi A, Axel L. Avascular necrosis of the hip: comparison of MR, CT, and scintigraphy. AJR Am J Roentgenol 1986;147:6771.

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Ulus Travma Acil Cerrahi Derg 2012;18 (4):358-360

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.48742

Perforation of Meckel’s diverticulum by a button battery: Report of two cases Düğme pilin neden olduğu Meckel divertikülü perforasyonu: İki olgu sunumu Bülent Hayri ÖZOKUTAN, Haluk CEYLAN, Sefa YAPICI, Sedat SIMSIK Ingested button battery perforation of Meckel’s diverticulum is extremely rare, with only two reported cases in the recent literature. Two additional preschool children who accidentally swallowed an alkaline button battery and developed a perforated Meckel’s diverticulum are reported.

Surgeons should be aware of this rare complication. Careful clinical, radiologic and laboratory monitoring of children who ingest a button battery is advisable.

Yutulan düğme pilin neden olduğu Meckel divertikülü perforasyonu oldukça nadirdir ve literatürde günümüze kadar yalnızca iki olgu bildirilmiştir. Bu yazıda, okul öncesi çağdaki iki çocukta kazayla yutulan düğme pilin yol açtığı Meckel divertikülü perforasyonu sunuldu. Düğme pil yutan çocuklarda gelişebilecek bu nadir komplikasyon akılda tutulmalı, olguların klinik, radyolojik ve laboratuvar bulguları dikkatle izlenmelidir.

Key Words: Button battery; foreign body; Meckel’s diverticulum; perforation.

Anahtar Sözcükler: Düğme pil; yabancı cisim; Meckel divertikülü; perforasyon.

Swallowed foreign bodies account for a significant number of emergency admissions of children.[1] An ingested foreign body generally causes no morbidity.[2] However, those that lodge in the gastrointestinal (GI) tract can cause significant complications.[3] Perforation of a Meckel’s diverticulum is a very rare complication of foreign body ingestion. A variety of foreign bodies, such as fish bones, needles and chicken bones, have been reported as causing perforation of a Meckel’s diverticulum.[4,5] Perforation of Meckel’s diverticulum by a button battery is exceptional and, to the best of our knowledge, only two cases have been reported in the English-language literature.[6,7] In this study, we report two further cases.

CASE REPORTS Case 1– A 3-year-old boy who swallowed a button battery that he took out of from his toy three days before was brought to our emergency department. The child had first been admitted and observed in another pediatric surgery clinic for 2 nights. As the foreign

body had not changed its position on plain abdominal radiographs and the boy developed abdominal pain and vomiting, he was referred to our hospital for further management. On examination, he had lower abdominal tenderness. Laboratory data were normal except for leukocytosis of 15.8 x 103/μL. A plain abdominal radiograph showed the button battery in the lower abdomen, in the same position as on previous films; there was no evidence of free air (Fig. 1a). The abdomen was explored through a right lower quadrant incision, and this showed a perforated Meckel’s diverticulum from the button battery approximately 50 cm distal to the ileocecal valve. The perforation site was adherent to the rectum and ileum. An additional ileal perforation was present where the Meckel’s diverticulum was adherent to small bowel (Fig. 2a). The button battery was 10 mm in diameter and 3 mm in thickness and its envelope was intact. A segmental resection of the ileum including the Meckel’s diverticulum and adjacent ileal perforation site was performed. The child made an uneventful recovery.

Department of Pediatric Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey.

Gaziantep Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Gaziantep.

Correspondence (İletişim): Haluk Ceylan, M.D. Gaziantep Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Gaziantep, Turkey.

Tel: +90 - 342 - 360 60 60 e-mail (e-posta): halukceylan@gmail.com

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Perforation of Meckel’s diverticulum by a button battery

(a)

(b)

Fig. 1. (a) Case 1. The button battery is seen (arrow) in the pelvis on the plain abdominal radiograph; (b) Case 2. Radiograph showing the battery in the lower abdomen (arrow) and air-fluid levels throughout the abdomen.

(a)

Case 2– A previously fit 5-year-old boy was admitted to the emergency room two days after swallowing a button battery from a toy. On examination, his abdomen was soft with no guarding or tenderness. Routine laboratory blood tests were normal. An abdominal radiograph demonstrated a round metallic foreign body in the lower abdomen. On the day after admission, he developed abdominal pain and tenderness. A repeat plain abdominal radiograph showed that the button battery had not moved from its original position, and there was no evidence of free air (Fig. 1b).

His leukocyte count had increased to 14.5 x 103/μL. An urgent laparotomy was performed with a presumptive diagnosis of GI perforation. Examination of the ileum revealed an edematous and indurated Meckel’s diverticulum, which had been perforated by a button battery measuring 10 mm in diameter and 3 mm in thickness with an intact envelope. A small segment of the ileum and the perforated Meckel’s diverticulum were resected (Fig. 2b), and the child made an uneventful recovery.

Both cases had a Meckel’s diverticulum measuring 2 cm wide and 3-4 cm in length. Pathological examination showed focal ulceration and perforation of the diverticulum, but no evidence of ectopic mucosa. (b) Fig. 2. (a) Case 1. Perforation of a Meckel’s diverticulum by a button battery (white arrow). There was an additional perforation in the adjacent ileum where the Meckel’s diverticulum was adherent (black arrow); (b) Case 2. Macroscopic appeareance of the resected specimen. The button battery is visible through the perforation in the Meckel’s diverticulum (arrow).

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DISCUSSION Accidental ingestion of a foreign body is a common occurrence in children. In most cases, there is no resultant morbidity, but serious complications and fatalities have occasionally been reported.[2,3,8] Button batteries account for less than 2% of all foreign bodies ingested by children.[8,9] These batteries are widely 359

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used in toys and household electrical devices, and are easily accessible to children. Ingested button batteries are physically and chemically active, with the potential to cause intense tissue irritation. Perforation of the GI tract by an ingested button battery can occur by three mechanisms: i) electrical discharge and mucosal burn, ii) alkaline caustic injury due to leakage, and iii) pressure necrosis. These batteries may also be toxic due to the absorption of substances such as mercury.[10] Meckel’s diverticulum, the most common congenital malformation of the GI tract, is typically located on the anti-mesenteric border of the ileum in 2% of the population. It represents persistence of the vitellointestinal duct. Complications such as bleeding, diverticulitis, intussusception, and Meckel’s band obstruction are well recognized.[11] Perforation of a Meckel’s diverticulum due to an ingested foreign body is a very rare complication; fish bones, needles, chicken bones, and food items are the most common causes in such cases.[4,5] Perforation of Meckel’s diverticulum by a button battery is exceptional. Only two cases appear to have been reported before.[6,7] Both were in boys, aged 1 year and 2.5 years.

After ingestion of a button battery, management depends on its localization. Batteries lodged in the esophagus should be removed promptly. If a radiograph suggests that the button battery is in the stomach, endoscopic removal is recommended if the battery has not progressed within 24 hours.[9] Cases in which the button battery has passed into the bowel should monitored both clinically and radiologically for possible complications.[9] Abdominal tenderness, a static position of the foreign body on repeated plain abdominal radiographs and leukocytosis are worrying features.[6,9] All these features were present in both of our cases. The duration of conservative management varies between patients. Willis and Ho[6] operated on their patient on the third day after ingestion, whilst Karaman et al.[7] operated on their case on the sixth day after ingestion. Both of our cases underwent surgery three days after ingestion.

In the case reported by Karaman et al.,[7] the button battery perforated a Meckel’s diverticulum which was adherent to the cecum and appendix. Willis and Ho[6] described an area of superficial necrosis in the ileum that probably represented a point of contact with the perforated Meckel’s diverticulum. In our first case, the battery caused a perforation in a Meckel’s diverticulum and was stuck to a segment of the proximal

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ileum (causing an ileal perforation) and to the rectum.

In light of these observations, we recommend careful examination of adjacent bowel segments in operated cases to rule out additional pathology.

In conclusion, a swallowed button battery has the potential to cause GI perforation, particularly if it is held up in a Meckel’s diverticulum. Careful clinical, radiologic and laboratory monitoring of children who ingest a button battery is required. In those that require surgery, adjacent bowel segments should be carefully inspected to exclude additional associated pathology.

Acknowledgment The authors would like to thank Professor Mark D. Stringer of the Otago School of Medical Sciences of the University of Otago, Dunedin, New Zealand, for his helpful comments and for editing the grammar and style of the manuscript.

REFERENCES 1. Wahbeh G, Wyllie R, Kay M. Foreign body ingestion in infants and children: location, location, location. Clin Pediatr (Phila) 2002;41:633-40.

2. Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001;160:468-72.

3. Hamilton JM, Schraff SA, Notrica DM. Severe injuries from coin cell battery ingestions: 2 case reports. J Pediatr Surg 2009;44:644-7.

4. Rosswick RP. Perforation of Meckel’s diverticulum by foreign bodies. Postgrad Med J 1965;41:105-7.

5. Yagci G, Cetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg Today 2004;34:606-8.

6. Willis GA, Ho WC. Perforation of Meckel’s diverticulum by an alkaline hearing aid battery. Can Med Assoc J 1982;126:497-8.

7. Karaman A, Karaman I, Erdoğan D, Cavuşoğlu YH, Aslan MK, Varlikli O, et al. Perforation of Meckel’s diverticulum by a button battery: report of a case. Surg Today 2007;37:11156.

8. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int 2007;23:755-61.

9. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics 1992;89:74757.

10. Yardeni D, Yardeni H, Coran AG, Golladay ES. Severe esophageal damage due to button battery ingestion: can it be prevented? Pediatr Surg Int 2004;20:496-501.

11. Lloyd D. Omphalomesenteric duct remnants. In: Puri P, Höllwarth ME, editors. Pediatric surgery. 1st ed. Heidelberg: Springer-Verlag; 2006. p 327-32.

Temmuz - July 2012

Turkish Journal of Trauma & Emergency Surgery Case Report

Ulus Travma Acil Cerrahi Derg 2012;18 (4):361-363 Olgu Sunumu doi: 10.5505/tjtes.2012.26817

Subcutaneous emphysema and pneumomediastinum complicating a dental procedure Dental işlemin komplikasyonu olarak gelişen cilt altı amfizemi ve pnömomediasten İsa DÖNGEL,1 Mehmet BAYRAM,2 İsmail Önder UYSAL,3 Güven Sadi SUNAM4

Cervicofacial emphysema and pneumomediastinum are rarely observed complications of dental interventions. The complications are associated with the use of a high-speed air-turbine dental drill. It is a potentially life-threatening condition, but the majority of cases are self-limiting and benign. We describe a patient with remarkable subcutaneous emphysema, pneumomediastinum, and partial pneumothorax after right second mandibular molar extraction. Dentists and physicians more often attribute the rapid onset of dyspnea in patients after a dental procedure to an allergic reaction to the anesthesia used during the procedure. Dentists and physicians should be aware that soft tissue emphysema can cause acute swelling of the cervicofacial region after dental procedures, which may mimic an allergic reaction.

Servikofasyal amfizem ve pnömomediasten dental girişimlerden sonra nadiren gelişen komplikasyonlardır ve yüksek hızlı hava türbinli dental matkap kullanımı ile ilişkilidir. Yaşamı tehdit etme potansiyeli olan bir durum olsa da olguların büyük çoğunluğunda kendini sınırlar ve tehlike oluşturmaz. Bu yazıda sağ alt ikinci molar diş çekimi sonrasında gözle görülür cilt altı amfizemi, pnömomediasten ve parsiyel pnömotoraks gelişen hasta sunuldu. Diş hekimleri ve hekimler dental işlemi takiben ani dispne gelişmesini daha çok kullanılan anesteziklere karşı alerjik reaksiyona bağlama eğilimindedirler. Diş hekimleri ve hekimler dental işlem sonrası alerjik reaksiyonu taklit eden cilt altı amfizemine bağlı servikofasyal bölgede yumuşak dokuda şişme olabileceği konusunda dikkatli olmalıdırlar.

Key Words: Dental procedure; pneumomediastinum; subcutaneous emphysema.

Anahtar Sözcükler: Dental işlem; pnömomediasten; cilt altı amfizemi.

Cervicofacial emphysema and pneumomediastinum are rare complications of dental procedures.[1] While mostly benign and self limiting, life-threatening conditions may occur if the complications go unrecognized. Unaware physicians may consider this entity as an allergic reaction.

We present a case of cervicofacial emphysema, pneumomediastinum and pneumothorax occurring in a 46-year-old female following the removal of the right second mandibular molar.

CASE REPORT A 46-year-old female was referred to the emergency department with a history of central dyspnea, chest pain and bilateral cervical swelling. One hour before, she had undergone a lower right second molar surgical extraction under local anesthesia by a general dental practitioner. Her general condition was fine, with a pulse of 80/min, blood pressure of 110/70 mmHg, respiratory rate of 16/min, temperature of 36.8°C, and maintaining oxygen saturation of 97%. The examina-

Departments of 1Thoracic Surgery, 2Chest Disease, Sivas State Hospital, Sivas; 3Department of Otorhinolaryngology, Cumhuriyet University Faculty of Medicine, Sivas; 4Department of Thoracic Surgery, Selcuklu University Faculty of Medicine, Konya, Turkey.

Sivas Devlet Hastanesi, 1Göğüs Cerrahisi Kliniği, 2Göğüs Hastalıkları Kliniği, Sivas; 3Cumhuriyet Üniversitesi Tıp Fakültesi, KBB Hastalıkları Anabilim Dalı, Sivas; 4Selçuklu Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Konya.

Correspondence (İletişim): Mehmet Bayram M.D. Bezmialem Vakıf Üniversitesi Göğüs Hastalıkları Anabilim Dalı, Fatih, İstanbul, Turkey.

Tel: +90 - 212 - 453 17 10 / 1253 e-mail (e-posta): drmehmetbayram@yahoo.com

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tion revealed bilateral neck swelling and trachea in midline, with crepitus on palpation, suggesting profound cutaneous emphysema. Her chest radiograph showed an extensive subcutaneous emphysema, pneumomediastinum and partial pneumothorax on the right side, as shown in Fig. 1.

A thorax catheter was inserted to the right hemithorax. 100% oxygen was supplied using a facemask for the first two days. The patient was also managed conservatively with intravenous antibiotics and analgesics. The cervicofacial swelling and crepitus subsided, and partial pneumothorax was resorbed within the next three days. Computerized tomography of the thorax showed the air through the tissue planes to the mediastinum and aortic arch and subcutaneous region (Figs. 2a, b) on the 5th day. The patient was discharged from the hospital in good condition.

DISCUSSION Cervical emphysema and pneumomediastinum can be defined as the presence of air in subcutaneous soft tissue and mediastinum. This clinical condition is reported to be caused by a high-speed air-turbine dental drill or other pressured appliances used during dental procedures.[2,3] These appliances can introduce the pressured air into the soft tissues. Especially in procedures involving the molar teeth, air can diffuse the pterygomandibular region and lateral pharyngeal spaces from the retromolar region.[4] The presence of free air on the retropharyngeal space may lead to eustachian tube dysfunction and hearing loss, dysphonia and dysphagia.[5] The roots of molar teeth are connected directly with the submandibular space, which communicates with the retropharyngeal space and mediastinum. Air can also reach the retroperitoneum and pleural cavity. It is reported that subcutaneous emphysema and pneumomediastinum can also be seen after (a)

Fig. 1. Chest radiography showing pneumomediastinum and subcutaneous emphysema.

sneezing and nose blowing.[6] Crepitus on palpation and tenderness are findings of cervical emphysema.

Retrosternal pain and dyspnea are characteristic findings of pneumomediastinum. The sign of pneumomediastinum includes dull cardiac sound and mediastinal crepitation with systolic contraction heart (Hammanâ&#x20AC;&#x2122;s sign). Venous distension, hypotension, hypercarbia, and acidosis are life-threatening consequences of massive air trapping in the mediastinum. Roentgenographic evidence of air within the mediastinum is diagnostic for this entity. Free air is readily seen as a thin line of (b)

Fig. 2. (a) Axial computerized tomography of the thorax showing air in the mediastinum. (b) Axial computerized tomography of the thorax showing air within upper anterior chest wall.

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Subcutaneous emphysema and pneumomediastinum complicating a dental procedure

radiolucency outlining the cardiac border on posteroanterior chest radiography (Fig. 1). Treatment of pneumomediastinum and subcutaneous emphysema is usually conservative. Nitrogen washout with inhalation of 100% oxygen is suggested. Microorganisms of the oral cavity flora can easily migrate to the mediastinum and cause mediastinitis.[7] In this case, broad-spectrum antibiotics be administered.

Antitussives and laxatives may be used to prevent air embolism due to high intrathoracic pressure. Most of the cervical emphysema and pneumomediastinum cases are benign and self-limiting. However, tracheal compression, pneumopericardium, tension pneumomediastinum, and cardiac tamponade are life-threatening complications. Infective mediastinitis and sepsis may also occur. Recognition of cervical emphysema and pneumomediastinum is easy; however, it is essential to be aware of this entity, which may occur after dental procedures. Otherwise, dentists and emergency

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physicians may misdiagnose the condition as an allergic reaction, hematoma or infection.

REFERENCES 1. Guest PG, Henderson S. Surgical emphysema of the mediastinum as a consequence of attempted extraction of a third molar tooth using an air turbine drill. Br Dent J 1991;171:283-4.

2. Monsour PA, Savage NW. Cervicofacial emphysema following dental procedures. Aust Dent J 1989;34:403-6.

3. Szubin L, La Bruna A, Levine J, Komisar A. Subcutaneous and retropharyngeal emphysema after dental procedures.

Otolaryngol Head Neck Surg 1997;117:122-3.

4. Cardo VA Jr, Mooney JW, Stratigos GT. Iatrogenic dental-air emphysema: report of case. J Am Dent Assoc 1972;85:144-7.

5. Stillman PL, Ruggill JS, Rutala PJ, Dinham SM, Sabers DL. Students transferring into an American medical school. Remediating their deficiencies. JAMA 1980;243:129-33.

6. Damore DT, Dayan PS. Medical causes of pneumomediastinum in children. Clin Pediatr (Phila). 2001;40:87-91.

7. Reznick JB, Ardary WC. Cervicofacial subcutaneous air emphysema after dental extraction. J Am Dent Assoc 1990;120:417-9.

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Ulus Travma Acil Cerrahi Derg 2012;18 (4):364-366

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.67674

Late-onset spinal accessory nerve palsy after traffic accident: case report Trafik kazası sonrasında geç gelişen spinal aksesuvar sinir lezyonu: Olgu sunumu Tamer TEKİN,1 Tolga EGE2

An injury to the spinal accessory nerve is mostly reported after surgical procedures performed in the posterior triangle of the neck. In addition, it may be caused by fractures in the jugular foramina, traumas or skull base tumors. Clinically, paralysis of the trapezius muscle leads to weakness, downward rotation of the scapulae and falling down of the shoulder girdle. A 38- year-old male with left shoulder pain, scapular deviation and weakness in the left upper extremity, whose symptoms developed over a two-year period following a traffic accident, is presented herein. In the electromyography (EMG) study, partial spinal accessory nerve palsy was detected. The patient was treated conservatively for the nerve palsy since the time elapsed rendered surgical intervention inappropriate. We report a case in which spinal accessory nerve palsy developed two years after a traffic accident. Accessory nerve injury following a traffic accident is very uncommon.

Spinal aksesuvar sinir, trapezius ve sternokleidomastoid kaslarının ana motor inervasyonunu sağlar. Spinal aksesuvar sinir yaralanmalarının en sık nedeni, iyatrojenik olarak arka boyun üçgeninde yapılan cerrahi girişimlerdir. Buna ek olarak ise juguler foramendeki kırıklar, kafa tabanı tümörleri, travmalar da neden olabilir. Klinik olarak trapezius kasındaki kuvvetsizlik, omuz kuşağında düşme ve skapulanın aşağı ve dışa rotasyonuyla kanatlı skapulaya yol açar. Otuz sekiz yaşında erkek hasta, öyküsünde araç içi trafik kazasından iki yıl kadar sonra sol kol ve omuzda ağrı, kuvvetsizlik, skapulada deviyasyon yakınmaları nedeni ile merkezimize başvurdu. Yapılan elektromiyelografi (EMG) incelemesinde sol aksesuvar parsiyel sinir lezyonu tanısı kondu ve takip önerildi. Cerrahi tedavi yapılabilecek olan süreci geçirmesi nedeni ile konservatif tedavi önerildi. Bu yazıda, trafik kazasını takiben iki yıl sonra aksesuvar sinir lezyonu gelişen bir erkek olgu sunuldu. Trafik kazası sonrası aksesuvar sinir lezyonu son derece nadirdir.

Key Words: Late onset; spinal accessory nerve palsy; traffic accident.

Anahtar Sözcükler: Geç gelişen; spinal aksesuar sinir paralizisi; trafik kazası.

The spinal accessory nerve (SAN) may be injured at any point along its course.[1] Because of its superficial location in the posterior cervical triangle, it is especially susceptible to damage from penetrating injuries.

It may also be injured during operations such as lymph node biopsy or radical neck dissection.[1] Woodhall[2] has given an accurate description of the symptoms and findings that follow surgical injury to this nerve: the patient complains of generalized weakness in the affected shoulder girdle and arm, inability to abduct the shoulder above 90°, and a sensory disturbance that may vary from a pulling sensation in the region of the

scar to aching in the shoulder and arm. The aching may radiate to the medial margin of the scapula and down the arm to the fingers, and is sometimes incapacitating.

The superior one-third of the trapezius muscle on the affected side always atrophies, the shoulder sags, and power to elevate it is weak. The scapula rotates distally and laterally and flares slightly; its inferior angle is closer to the midline than is its superior angle. This position is accentuated when the arm is abducted; the flaring of the inferior angle disappears when the arm is raised anteriorly, in contrast to the usual deformity caused by paralysis of the serratus anterior.[3]

Departments of 1Neurosurgery, 2Orthopaedics and Traumatology, Military Hospital, Van, Turkey.

Van Asker Hastanesi, 1Nöroşirurji Kliniği, 2 Ortopedi ve Travmatoloji Kliniği, Van.

Correspondence (İletişim): Tamer Tekin, M.D. Van Asker Hastanesi, İskele Cad., 65100 Van, Turkey.

Tel: +90 - 432 - 222 33 29 e-mail (e-posta): tamer.tekin@yahoo.com.tr

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Late-onset spinal accessory nerve palsy after traffic accident

CASE REPORT A 38-year-old male with symptoms of left shoulder pain and weakness in the left upper extremity was admitted to our clinic two years following a traffic accident. Upon presentation to our clinic, the patient complained of pain at the base of his neck and left upper back, without upper extremity radiation. The pain was increased by sitting with his arm unsupported, by prolonged standing and overhead activities. He also complained of asymmetry of the shoulders and decreased range of motion. The physical examination demonstrated marked wasting of the trapezius muscle, and the lateral border of the left scapula was noted to appear more prominent or to wing with abduction, but not with forward flexion (Fig. 1). Active movements were restricted to 90° abduction and flexion due to pain. He had a full range of passive movements, the rotator cuff was intact and neurological examination of motor function of the left trapezius muscle was 2/5.

Plain radiographs were normal. In the electromyography (EMG) study, partial spinal accessory nerve palsy (SANP) was detected. The patient was treated conservatively. After one year, repeated EMG study showed a delay in the motor potentials of the left SAN compared to the right side and the reference values of normal. In view of the time elapsed, surgical intervention was not appropriate in this patient, and he was thus referred for physical therapy. The goal of the treatment was to decrease pain both at rest and with functional activities and to increase left upper extremity function.

Passive range of motion of the left glenohumeral joint was performed to maintain glenohumeral range of motion. The patient reported a decrease in pain over the following one month.

DISCUSSION The accessory nerve is a “purely” motor nerve; it consists of a cranial root and spinal root. The cranial root arises from the caudal segment of the nucleus

Fig. 1. Image showing winging of the left scapula.

Cilt - Vol. 18 Sayı - No. 4

ambiguous and runs laterally toward the jugular foramen, where it unites with the spinal root. The spinal root originates from the nucleus of the SAN, which extends from C1-C6. The spinal root runs between the dorsal roots of the spinal nerves and the dentate ligament, upwards through the foramen magnum, where it meets the cranial root.[4] After exiting the cranium, the accessory nerve passes deep to the sternocleidomastoid and then passes under the trapezius muscle. It innervates these two muscles; the sternocleidomastoid rotates the head to the opposite side, and the trapezius stabilizes the scapula, elevates (shrugs) the shoulder, and assists with scapular adduction and arm abduction at the shoulder.[5] The diagnosis of SANP usually relies on a pertinent history and examination. Weakness and atrophy that begins after a surgical procedure or penetrating trauma is often the case. On examination, the affected shoulder is in a lower position (drooping) compared to the normal shoulder, trapezoidal atrophy is present, and some winging of the scapula may be evident at rest.[5,6] These are some of the more useful examination findings; therefore, the diagnosis can often be made with careful observation alone. There is weakness of shoulder shrug; however, the patient can often still shrug the shoulder, and some patients even have a symmetrical shrug because this movement is also performed by the levator scapula, which is innervated by the dorsal scapular nerve.[5] The trapezius assists in arm abduction above 90°; therefore, patients have trouble with this movement. When the patient windmills their arms in abduction overhead, incoordination of the affected scapula can be seen. Scapular winging also occurs, which unlike a serratus anterior palsy, does not persist when the arm and shoulder are protracted forward.[5,6] When the sternocleidomastoid muscle is weak or atrophic, skull base and foramen magnum pathology should be excluded with magnetic resonance imaging (MRI). Electrodiagnostic testing confirms injury to the SAN, and can help evaluate partial injuries, or those with early reinnervation.[7] Nevertheless, some partial injuries without denervation may be difficult to diagnosis. Because the SAN is superficial and readily exposed, early surgical exploration and repair should be considered, especially with iatrogenic or sharp, lacerating injuries.[1,7] Alternatively, when nerve continuity is likely, or if partial function is present, it may be prudent to observe these patients for 3-6 months with serial electrodiagnostic tests, and explore those patients who fail to recover. Transected nerves should be repaired directly, or with an interposition nerve graft obtained from the greater auricular or sural nerve. If the nerve is not found transected and positive nerve action potentials are present, then an external neurolysis should be performed.[1,8,9] For patients who do not have a viable proximal accessory nerve stump to repair (e.g., after it was removed with a 365

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skull base tumor), a split thickness nerve transfer from the hypoglossal to the SAN should be considered. For chronic palsies (older than 1-2 years), where nerve surgery is no longer an option, one may undergo a tendon transfer where the levator scapulae and rhomboids are advanced from under the scapula to over the margin of the scapula.[7,10-12] Few cases of SANP secondary to stretch or traction injury have been reported in the literature. Two separate cases were reported to follow lifting heavy objects. To our knowledge, there is one case report in the English literature of SANP one year after a traffic accident.

In conclusion, there have been many causes of SANP reported in the literature. We found one case report about SANP following whiplash injury. We report the second case of SANP after a traffic accident, this case occurring two years later. Lesions of the SAN can be identified and differentiated from other clinical entities by careful history and physical examination.

The treatment of SANP should be comprehensive and begin as early as possible. A high index of suspicion for SANP should be present following traction-type injuries to the cervical spine. Early diagnosis and treatment of SANP may lead to more effective pain relief and better functional outcome.

REFERENCES 1. Chan PK, Hems TE. Clinical signs of accessory nerve palsy.

J Trauma 2006;60:1142-4.

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2. Woodhall B. Operative injury to the accessory nerve in the posterior cervical triangle; comment upon the abduction test for trapezius muscle paralysis. AMA Arch Surg 1957;74:1227.

3. Porter P, Fernandez GN. Stretch-induced spinal accessory nerve palsy: a case report. J Shoulder Elbow Surg 2001;10:92-4.

4. Ozdemir O, Kurne A, Temuรงin C, Varli K. Spontaneous unilateral accessory nerve palsy: a case report and review of the literature. Clin Rheumatol 2007;26:1581-3.

5. Bodack MP, Tunkel RS, Marini SG, Nagler W. Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report. J Pain Symptom Manage 1998;15:321-8.

6. Olarte M, Adams D. Accessory nerve palsy. J Neurol Neurosurg Psychiatry 1977;40:1113-6.

7. Braybrooke J, Kumar C, Morris E. Spinal accessory nerve palsy following blunt trauma. Injury 2003;34:948-9.

8. Nakamichi K, Tachibana S. Iatrogenic injury of the spinal accessory nerve. Results of re-pair. J Bone Joint Surg Am 1998;80:1616-21.

9. Novak CB, Mackinnon SE. Patient outcome after surgical management of an accessory nerve injury. Otolaryngol Head Neck Surg 2002;127:221-4.

10. Bigliani LU, Compito CA, Duralde XA, Wolfe IN. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. J Bone Joint Surg Am 1996;78:1534-40.

11. Romero J, Gerber C. Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure. J Bone Joint Surg Br 2003;85:1141-5.

12. Teboul F, Bizot P, Kakkar R, Sedel L. Surgical management of trapezius palsy. J Bone Joint Surg Am 2005;87:285-91.

Temmuz - July 2012

Değerli Meslektaşlarım, Sizileri 19-23 Nisan 2013 tarihleri arasında Antalya’da gerçekleşecek olan 9. Ulusal Travma ve Acil Cerrahi Kongresi’ne davet etmekten mutluluk duyuyoruz.

Bu kongre ile, Travma, Acil Cerrahi ve Acil Tıp alanında en üst düzeyde bilgi birikimi ve yoğun deneyimle elde edilebilecek, tanı, tedavi, organizasyon ve hasta bakımı alanındaki tüm gelişmeler bilgilerinize sunulacaktır.

Kongre programı kongre öncesi kursları, uzman oturumları, video sunumları, interaktif paneller, tartışma oturumları, uzlaşma toplantıları, konferanslar ve uzmanlık alanında gerçekleşen yenilikleri içermektedir.

Hedefimiz değerli görüşlerinizle bilimsel programımızı zenginleştirip, herkesin birbirinden bir şeyler öğrenebileceği bir platform yaratmaktır.

Antalya tarih boyunca kültürün, sanatın, mimarinin ve mitolojinin merkezi olmuştur. Muhteşem doğası, açık maviden laciverte uzanan denizi, şelaleleri, Toros dağları ve palmiye ağaçları ile bu gölgenin büyüsüne kapılacaksınız. Bu özellikleri ile de Antalya, Travma ve Acil Cerrahideki son gelişmeleri tartışabileceğimiz en uygun yer.

Sizi Antalya’da ağırlamaktan büyük memnuniyet duyacağız.

Saygılarımızla, Recep Güloğlu

Salih Pekmezci

Ulusal Travma ve Acil Cerrahi Derneği Başkanı

Kongre Başkanı

DÜZENLEME KURULU Kongre Başkanı Salih PEKMEZCİ Kongre Eş Başkanı Tayfun YÜCEL Genel Sekreter M. Mahir ÖZMEN Bilimsel Sekreterya Kaya SARIBEYOĞLU Hakan YANAR Üyeler Ediz ALTINLI Acar AREN Gürhan ÇELİK Cemalettin ERTEKIN Recep GÜLOĞLU Ahmet Nuray TURHAN