Travma 2014 4 by KAREPUBLISHING

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Volume 20 | Number 4 | July 2014

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu (Managing Editor) Hakan Yanar M. Mahir Özmen Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (Başkan Yardımcısı) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Recep Güloğlu Kaya Sarıbeyoğlu M. Mahir Özmen Ali Fuat Kaan Gök Hakan Teoman Yanar Gürhan Çelik Osman Şimşek

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Amblem Correspondence address (Yazışma adresi) Tel Fax (Faks)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

Annual subscription rates: 75.- (USD) Abonelik: 2013 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. p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Corinne Can • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): July (Temmuz) 2014 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE www.tjtes.org

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.

tion, called “Upload Your Files”.

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.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

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. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. 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” sec-

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.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: 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. 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. Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies. Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above. Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors. Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

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. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. 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 190210 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.

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 4 July - Temmuz 2014

Contents - İçindekiler

Experimental Study - Deneysel Çalışma Deneysel Çalışma - Experimental Study 227-230 Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury Deneysel penetran toraks yaralanmasına bağlı kardiyak ve pulmoner yaralanmaların analizi Tokur M, Ergin M, Okumuş M 231-235 The effects of oral antibiotics on infection prophylaxis in traumatic wounds Travmatik yaralarda oral antibiyotiklerin enfeksiyon profilaksisindeki etkileri Erbil B, Ersoy G, Özkütük A, Karbek Akarca F, Korkmaz T, Demir ÖF, Kıyan S

Original Articles - KlinikArticles Çalışma Klinik Çalışma - Original 236-240 Correlation between arterial blood gas analysis and outcome in patients with severe head trauma Ciddi kafa travması olan hastalarda sonlanımla arter kan gazı analizi arasındaki korelasyon Bazzazi A, Valizade Hasanloei MA, Mahoori A, Gholamnejad M, Tarverdipour H 241-247 Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department Acil servise başvuran majör travma hastalarının mortalite tahmininde Glasgow koma skalası, yaş ve arteriyel kan basıncı skorunun değerliliği Ahun E, Köksal Ö, Sığırlı D, Torun G, Dönmez SS, Armağan E 248-252 Impact of smoking on trauma patients Travma hastalarında sigaranın etkisi Resnick S, Inaba K, Okoye O, Nosanov L, Grabo D, Benjamin E, Smith J, Demetriades D 253-257 Etiology and prognosis of penetrating eye injuries in geriatric patients in the Southeastern region of Anatolia Turkey Güneydoğu Anadolu Bölgesi’ndeki geriatrik hastalarda delici göz yaralanmalarında etiyoloji ve prognoz Yüksel H, Türkcü FM, Çınar Y, Cingü AK, Şahin A, Şahin M, Özkurt Z, Murat M, Çaça İ 258-264 Comparison of trauma scores for predicting mortality and morbidity on trauma patients Travma hastalarında mortalite ve morbidite öngörüsünde travma skorlamalarının karşılaştırılması Orhon R, Eren ŞH, Karadayı Ş, Korkmaz İ, Coşkun A, Eren M, Katrancıoğlu N 265-274 Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis Fournier gangreninde 80 hastalık tecrübemiz ve bir etiyopatogenez nedeni olarak “travma” Eskitaşcıoğlu T, Özyazgan İ, Çoruh A, Günay GK, Altıparmak M, Yontar Y, Doğan F 275-280 Management of ankle sprains during pregnancy: evaluation of 96 cases Gebelikte ayak bileği burkulmalarına yaklaşım ve tedavi: 96 olgunun değerlendirilmesi Işık Ç, Tahta M, Işık D, Üstü Y, Uğurlu M, Bozkurt N, Bozkurt M

Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 4 July - Temmuz 2014

Contents - İçindekiler

281-285 Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients: 14 years of experience in a burn unit Yüz elli dokuz pediyatrik hastada sıcak süt nedeniyle görülen yanık travmasının geriye dönük analizi: Bir yanık ünitesindeki 14 yıllık deneyim Yontar Y, Esmaoglu A, Coruh A 286-290 Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları The results of low profile locking anatomical plate application for the treatment of Edinburg type 2 clavicle diaphysis fractures Akgül T, Zehir S, Özdemir G, Yücel F, Türk A, Çiçekli Ö

CaseSunumu Reports- -Case OlguReports Sunumu Olgu 291-294 Ergotamine-induced vasospastic ischemia mimicking arterial embolism: unusual case Arteriyel emboliyi taklit eden ergotamine bağlı vazospastik iskemi: Nadir bir olgu Adam G, Kurt T, Çınar C, Sarıyıldırım A, Resorlu M, Uysal F, Yener AÜ, Özcan S, Saçar M, Özdemir H 295-299 Successful surgical rescue of delayed onset diaphragmatic hernia following radiofrequency ablation for hepatocellular carcinoma Hepatoselüler karsinom için uygulanan radyofrekans ablasyon sonrası oluşan geç başlangıçlı diyafragma hernisinin başarılı cerrahi onarımı Nakamura T, Masuda K, Thethi RS, Sako H, Yoh T, Nakao T, Yoshimura N 300-304 Surgical treatment of a Malgaigne fracture Malgaigne kırığı’nın cerrahi tedavisi Dalbayrak S, Ayten M, Özer F, Yaman O 305-307 Thyroid storm due to head injury Kafa travmasına bağlı tiroit fırtınası Karaören GY, Sahin OT, Erbesler ZA, Bakan N 308-310 Swallowed a needle stuck in heart Yutulup kalbe saplanmış iğne Yolcu M, Aydın A, Korkmaz AF, Dağ Ö, İpek E, Erkut B

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Ulus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, No. 4

EXPERIMENTAL STUDY

Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury Mahmut Tokur, M.D.,1 Mehmet Ergin, M.D.,2 Mehmet Okumuş, M.D.3 1

Department of Thoracic Surgery, Sutcu Imam University Faculty of Medicine, Kahramanmaras;

Department of Emergency Medicine, Konya Necmettin Erbakan University Faculty of Medicine, Konya;

Department of Emergency Medicine, Sutcu Imam University Faculty of Medicine, Kahramanmaras

ABSTRACT BACKGROUND: This study was planned to analyze the internal and external anatomical findings of cardiac injuries and the presence of accompanying pulmonary injuries in intentionally inflicted thoracic injuries to swine models. METHODS: We inflicted a penetrating heart injury in six suis domesticus female swine models. Two cardiac injuries, one on the left paratracheal of fourth intercostal space (ICS) and the other on the right side were inflicted on each model by the same researcher using a 20-cm long scalpel. All animals were then sacrificed for morphological evaluation. RESULTS: After strikes to the left fourth ICS, external evaluation showed that 50% of the subjects suffered a single laceration and that 33% suffered multiple lacerations. Internal evaluation showed additional intracardiac injuries in all five subjects. However, the subject that suffered a single laceration on the outer surface of the heart had multiple internal injuries while another subject that had multiple outer lacerations had only one intracardiac injury. Only three subjects suffered cardiac injuries and only two out of those three with pulmonary injuries after right fourth intercostal intrusions. CONCLUSION: This experiment has shown that external evaluation of the heart tissue may not alone be sufficient to determine the extent of cardiac injuries and accompanying pulmonary injuries caused by penetrating thoracic injuries. Key words: Myocardial injury; penetrating; trauma.

INTRODUCTION

MATERIALS AND METHODS

Although rarely seen, penetrating heart injuries are important thoracic pathologies because they carry a high-risk for mortality and require rapid diagnosis and treatment.[1] We conducted this study to analyze the internal and external anatomical findings of cardiac injuries and the presence of accompanying pulmonary injuries in intentionally inflicted thoracic injuries to swine models and explained the mechanisms that contribute to high mortality rates in related injuries.

Overview of the Experimental Animal Groups

Address for correspondence: Mehmet Ergin, M.D. Sille Parsana Mahallesi, Barış Caddesi, Lale Park Evlerino: 111/4, Selçuklu, Konya, Turkey Tel: +90 332 - 223 65 00 E-mail: drmehmetergin@gmail.com Qucik Response Code

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Six suis domesticus type female swine models, all of which were 1-year-old and weighed between 50 kg and 55 kg, were used in this experiment. All animals were kept under 12 hour/12 hour light/dark cycle at a constant temperature (22°C) and allowed free access to food and tap water. All experimental procedures were approved by the Cukurova University School of Medicine Ethical and Experimental Committee. All investigators complied with the 1996 “Guide for the Care and Use of Laboratory Animals.” All efforts were undertaken to reduce the total number of animals required for the experiment and to minimize their discomfort. Feeding of the animals was stopped 24 hours prior to experiment, with water being available until 2 hours prior. Intravenous cannulations were performed in animals through V. Auricularis lateralis and infusion of 0.9% isotonic saline was started at the beginning of the experiment. Atropine sulfate at 0.2 mg/kg was given to reduce secretions prior to anesthesia. Xylazine (Rompun), at a dose of 2 mg/kg, and ketamine, at a dose of 13 mg/kg, were started to induce anesthesia, and this combination continued 227

Tokur et al. Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury

the third subject (Table 1). All injured subjects had lacerations on the frontal surface of the left ventricle, with additional damage to coronary arteries in two of these subjects. External evaluation showed that 50% of the subjects suffered a single laceration and that 33% suffered multiple lacerations. Intracardiac evaluation showed additional injuries in all five subjects. We found a partial interventricular septum injury and a full-layer mitral valve papillary muscle injury in one subject; partial interventricular septum injury in one subject; partial mitral valve papillary muscle injury in one subject; and partial left ventricle posterior wall injuries in two subjects. Based on these observations, the subject that suffered a single laceration on the outer surface of the heart had multiple internal injuries, while subjects that had multiple external lacerations had only one intracardiac injury. All five subjects who had cardiac injuries also had pulmonary injuries.

to be infused throughout the experiment. Supplemental oxygen was provided to the subjects during the experiment.

Induction of Penetrating Thorax Injury and Insertion of Catheters and Thoracotomy Operation Thoraces of the animals covering the sternum and ribs were shaved and then properly disinfected using povidone iodine (Batikon速) solution. Two cardiac injuries, one on the left paratracheal of fourth intercostal space (ICS) and the other on the right paratracheal of fourth ICS were inflicted on each model by the same researcher using a 20-cm long scalpel (Fig. 1a). All animals were then sacrificed with high dose ketamine hydrochloride. The hearts of the animals were removed for morphological evaluation. The outer surfaces of the hearts were opened first, followed by the left ventricles and then the right ventricles and injury tracings were evaluated and classified (Fig. 1b-d). Accompanying pulmonary injuries were also detected and recorded. The data is given as a number or percentages in the text.

Only three subjects suffered cardiac injuries resulting from right 4th intercostal incursion, while the other three had no injuries (Table 2). External morphological evaluation showed that all of these injuries were to the right ventricles. One subject had further damage to the apex cordis. On internal evaluation, two subjects had partial interventricular septum injuries whereas one subject had a full-layer interventricular

RESULTS Strikes to the left fourth ICS caused cardiac injuries in all, but

(a)

(b)

Y X

(c)

(d)

Figure 1. (a) Localization of entrance point for scalpel on both hemithorax. (b-d) The process for morphological evaluation of cardiac findings after penetrating thorax injury.

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Tokur et al. Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury

Table 1. Morphological signs explored following the injuries inflicted through the left 4th intercostal space paratracheal region Test subject

2 3 4

External cardiac injuries Left ventricle

+ – +

Coronary artery

–

+ – +

–

Internal cardiac injuries

Interventricular septum

+ (partial)

–

+ (partial)

Papillary muscle of mitral valve

+ (full layer)

–

+ (partial)

–

Posterior wall of left ventricle

–

+ (partial)

–

+ (partial)

–

Lung injuries

Left middle lobe

–

Left lower lobe

–

+: Injury was present; –: Injury wasn’t present.

Table 2. Morphological signs explored following the injuries inflicted through the right 4th intercostal space paratracheal region Test subject

External cardiac injuries

Right ventricle

–

Apex cordis

–

Internal cardiac injuries

Interventricular septum

–

+ (full layer)

+ (partial)

–

Lung injuries

Right middle lobe

–

Right lower lobe

–

+ (partial)

+: Injury was present; –: Injury wasn’t present.

septum injury. Only two out of those three models had accompanying pulmonary injuries. Injury tracing in the second subject was further investigated, and it was found that the scalpel penetrated the right fourth ICS and went through the right ventricle and interventricular septum, passed the left ventricle and exited on the other side of the heart after penetrating the apex cordis. Injuries to the left ventricle and coronary artery were concluded to result from left fourth ICS penetration while the injury to the apex cordis was a result of right fourth ICS penetration.

DISCUSSION Cardiac damage should be considered whenever injuries to the anterior thoracic region, medial to both nipples, and between the sternal jugulum and the upper abdomen are present, unless proven otherwise.[2] In our experimental model, we were able to observe eight cardiac injuries in 12 inflicted penetrating injuries to the thorax. There are intracardiac injuries reported in the literature folUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

lowing penetrating and even blunt thoracic trauma. Tokur et al. presented a case series of 11 penetrating cardiac injuries that were surgically intervened.[3] In their series, they detected a valve laceration in one patient in post-surgery echocardiography, a lacerated coronary artery in another patient during the surgery, and a left ventricle posterior wall injury in another patient. Cha et al. reported that among 71 penetrating cardiac injury patients observed over a period of 10 years, 48 survived their injuries and 11 had post-surgery sequales. Among their sequales were ventricular septal defects, aortic valvular damage, atrial septal defects, conduction defects, and tricuspid valvular lesions.[4] Jenson et al.[5] reported a case with atrial septal defects and mitral valve anterior leaflet perforation, which were detected and surgically repaired 7 years after sustaining a penetrating cardiac injury. In another study, Stahl et al. reported a case with tricuspid and mitral valve papillary muscle rupture and intraventricular septal rupture following a blunt trauma, and concluded that indirect forces that increase intraventricular hydrostatic pressures could cause ruptures in the atria or valves.[6] In our experiment, in which we evaluated the tracings of the injuries, we observed intracardiac injuries accompanying injuries to the external surface of the heart, with the possibility of multiple intracar229

Tokur et al. Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury

diac injuries even when only one injury was present on the external surface. Tokur et al.[3] reported accompanying pulmonary injuries in six patients out of 11 who suffered penetrating cardiac injuries. Similarly, Kaplan et al.[7] reported that in a series of 63 penetrating cardiac injury cases, 34% had accompanying pulmonary injuries. In another study, Yavuz et al.[8] reported that 54 (57.5%) out of 94 patients had isolated cardiac injuries, whereas 40 (42.5%) sustained additional injuries along with cardiac injuries, with the most common accompanying injuries being pulmonary injuries. Furthermore, they stated that the highest rate of mortality was observed in groups with accompanying pulmonary injuries. Our findings of accompanying pulmonary injuries are in line with the findings in the literature. Evidence in the literature shows that echocardiography performed in the emergency department to detect hemopericardium in penetrating and blunt cardiac injuries is an important diagnostic intervention and that the use of ultrasonography reduces the time between a patient’s arrival to the hospital and surgical intervention being performed.[9] On the other hand, detailed examinations such as computed tomography can be performed in only a few hemodynamically stable patients. Echocardiography evaluation performed prior to surgery provides valuable information in valvular and atrial/ventricular injuries. Performing transesophageal echocardiography during the surgery, on the other hand, can be useful in evaluating intraventricular injuries and valve functions in patients for whom pre-surgery echocardiography cannot be performed.[10] The results of our experiment showed that evaluation of the external surface of the heart is not sufficient to determine the severity of cardiac injury and/or the presence of accompanying pulmonary injury in injuries sustained following penetrating thoracic injuries. Physicians should therefore consider injuries to the external surface of the heart as the “tip of the iceberg” and explore for additional damage. Undetected intracardiac and pulmonary injuries may have complications and adverse effects during the post-surgery period. All these

indicate that thorough pre-surgery preparation and surgical exploration for damage should be performed in patients with penetrating cardiac injuries. However, it is known that there is not enough time, equipment, or personnel available for the application of heart-lung machines in all cases with penetrating cardiac injuries. Conflict of interest: The authors have no commercial associations or sources of support that might pose a conflict of interest. All authors have made substantive contributions to the study, and all authors endorse the data and conclusions. There is no conflict of interest between authors.

REFERENCES 1. Campbell NC, Thomson SR, Muckart DJ, Meumann CM, Van Middelkoop I, Botha JB. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737-40. 2. Çakır Ö, Eren Ş, Balcı AE, Özçelik C, Eren N. Penetrating cardiac injuries. [Article in Turkish] Türk Göğüs Kalp Damar Cer Derg 1999;7:112-6. 3. Tokur M, Ergin M, Kurkcuoglu C. Penetrating heart injuries and common difficulties encountered during emergency surgery. J Curr Surg 2012;2:89-95. 4. Cha EK, Mittal V, Allaben RD. Delayed sequelae of penetrating cardiac injury. Arch Surg 1993;128:836-41. 5. Jenson B, Kessler RM, Follis F, Wernly JA. Repair of atrial septal defect due to penetrating trauma. Tex Heart Inst J 1993;20:241-3. 6. Stahl RD, Liu JC, Walsh JF. Blunt cardiac trauma: atrioventricular valve disruption and ventricular septal defect. Ann Thorac Surg 1997;64:1466-8. 7. Kaplan M, Demirtaş M, Alhan C, Aka SA, Dağsalı S, Eren E, et al. Cardiac injuries: experience with 63 cases. [Article in Turkish] Türk Göğüs Kalp Damar Cer Derg 1999;7:287-90. 8. Yavuz C, Çil H, Başyiğit İ, Demirtaş S, İslamoğlu Y, Tekbaş G, et al. Factors affecting mortality in penetrating cardiac injuries: our 10-year. Turkish J Thorac Cardiovasc Surg 2011;19:337-43. 9. Rozycki GS, Feliciano DV, Ochsner MG, Knudson MM, Hoyt DB, Davis F, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999;46:543-52. 10. Meyer DM, Jessen ME, Grayburn PA. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: a prospective study. J Trauma 1995;39:902-9.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel penetran toraks yaralanmasına bağlı kardiyak ve pulmoner yaralanmaların analizi Dr. Mahmut Tokur,1 Mehmet Ergin,2 Mehmet Okumuş3 1 2 3

Sütçü İmam Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Kahramanmaraş; Konya Necmettin Erbakan Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Konya; Sütçü İmam Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kahramanmaraş

AMAÇ: Bu çalışmada, domuz deneklerde kasten yapılan torasik yaralanma sonucu meydana gelen kardiyak yaralanmaların iç ve dış anatomik bulguları ile eşlik eden pulmoner yaralanmaların incelenmesi amaçlandı. GEREÇ VE YÖNTEM: Biz altı adet suis domesticus cinsi dişi domuz denekte penetran kardiyak yaralanma oluşturduk. Aynı araştırmacı tarafından 20 cm uzunluğundaki bistüri ile biri sağ paratrakeal 4. interkostal aralıktan (İKA) ve diğeri sol paratrakeal 4. İKA’dan olmak üzere iki adet penetran kardiyak yaralanma gerçekleştirildi. Tüm hayvanlar morfolojik inceleme için sakrifiye edildi. BULGULAR: Sol 4. İKA’dan uygulanan darbe neticesinde dış yüzey incelemesi %50’sinde tek ve %33.3’ünde birden fazla kesi oluştuğunu gösterdi. İç yüzey incelemesi ise beş denekte ek intrakardiyak yaralanma olduğunu gösterdi. Ancak dış yüzeyde tek yaralanması olan denekte birden çok iç yüzey yaralanması, dış yüzeyde birden çok yaralanması olan denekte ise bir adet intrakardiyak yaralanma tespit edildi. Sağ 4. İKA’dan uygulanan darbe sonucunda ise üç denekte yaralanma oluştuğu ve üç domuzdan iki tanesinde akciğer yaralanmasının mevcut olduğu görüldü. TARTIŞMA: Bu deney, penetran toraks yaralanmaları sonucu oluşan kardiyak hasarın şiddetini ve eşlik eden akciğer yaralanmasını ortaya koymada, sadece kalp dış yüzey bulgularının yeterli olamayacağını işaret etmektedir. Anahtar sözcükler: Miyokardiyal hasar; penetran; travma. Ulus Travma Acil Cerrahi Derg 2014;20(4):227-230

230

doi: 10.5505/tjtes.2014.58538

Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

EXPERIMENTAL STUDY

The effects of oral antibiotics on infection prophylaxis in traumatic wounds Bülent Erbil, M.D.,1 Gürkan Ersoy, M.D.,2 Aydan Özkütük, M.D.,3 Funda Karbek Akarca, M.D.,2† Tanzer Korkmaz, M.D.,2* Ömer Faruk Demir, M.D.,2# Selahattin Kıyan, M.D.2† 1

Department of Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara;

Department of Emergency Medicine, Dokuz Eylul University Faculty of Medicine, Izmir;

Department of Medical Microbiology, Dokuz Eylul University Faculty of Medicine, Izmir

Current affiliation: †Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir;

*Department of Emergency Medicine, İzmir University Faculty of Medicine, Izmir;

Department of Emergency Medicine, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara

ABSTRACT BACKGROUND: The objective of this study is to examine the effectiveness of oral antibiotics in the prevention of infection development in traumatic wounds. METHODS: Forty Wistar albino rats were divided into five groups of eight animals. After the crushed wound model was made on the back of the rats, wounds were closed with a simple suture and Staphylococcus aureus ATCC 29213 strain was used to create infection. All rats apart from the controls were given oral gavage with antibiotics, including cephalexin, amoxicillin-clavulanate, clarithromycin (CAM), or levofloxacin for 5 days. Wounds were evaluated qualitatively and quantitatively on 5th day approximately 18 h after the last treatment. RESULTS: In the quantitative evaluation, no infection was observed in the treatment groups with amoxicillin-clavulanate, CAM, cephalexin, or levofloxacin. There was no significant difference on the numbers of bacteria found in the wounds among the groups. In terms of quantitative inflammation findings, no hyperemia or pus was detected in the groups that were given medication. Furthermore, no statistically significant difference was found among the groups in terms of induration. CONCLUSION: Oral prophylactic antibiotics have been found to be effective in the prevention of wound infection in the traumatic crushed wound model infected with S. aureus in rats. Key words: Antibiotic; prophylaxis; traumatic wound; wound infection.

INTRODUCTION The purpose of wound care is to protect it from infection and allow for a functional esthetic-looking scar development. The factors affecting infection development are the localization of the wound, duration, depth, configuration and contamination characteristics.[1,2] The presence of a foreign body or visible

Address for correspondence: Bülent Erbil, M.D. Hacettepeüniversitesi Erişkin Hastanesi, Acil Servis, Sıhhıye, 06100 Ankara, Turkey Tel: +90 312 - 305 25 05 E-mail: gantoerbil@gmail.com Qucik Response Code

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contamination increases the risk of infection.[1,2] Since more devitalized tissue is created in crush wounds inflicted by blunt objects, the risk of infection increases compared to those in inflicted with sharp objects. Although bacterial inoculation development and its amount are related to the time that passes between injury and repair,[1,3] the relationship between wound closure duration and clinical infection is not clear.[46] The etiology, location, degree of contamination risk factors of the host and the importance of cosmetic look of the wound are important in determining primary or secondary closure. If the infection risk is high, 4 days later, late primary closure should be considered.[7] Infection risk is determined by the interaction between the bacterial colonization and blood circulation. Therefore; anatomic localization is important to be able to estimate the clinical outcome of the infection.[1,2,4,8] The risk of infection is higher in lower extremities compared to the head and upper extremities. The number of bacterial colonization is high in 231

Erbil et al. The effects of oral antibiotics on infection prophylaxis in traumatic wounds

damp areas. In wounds contaminated with human or animal excretion, infection risk is high despite treatment.[7] Most of our knowledge concerning antibiotic prophylaxis was derived from experimental studies and surgical interventions. [9,10] What was learned from these studies is that before or right after wound contamination providing a fast antibiotic level determines the outcome and in most cases it is no use continuing the antibiotic after 24 hour. At the emergency department, antibiotic prophylaxis should be performed with effective agents against pathogens anticipated before obvious tissue manipulation. According to our knowledge, there are no studies comparing the initial dose taken intravenously or per-orally.[10] For the wounds closed at the emergency department, the infection rate is approximately 3-5%.[1] There is no conclusive evidence showing that antibiotic prophylaxis prevents wound infection in patients whose wounds are closed at the emergency department.[1,10,11] Common practice is to start antibiotic prophylaxis after treatment at the emergency department on the traumatic wounds with suspected infection. The aim of this study is to show and compare the effectiveness of oral cephalexin, amoxicillin-clavulanate, clarithromycin (CAM) and levofloxacin on the prevention of wound location infection development in traumatic crushed wounds inflicted on rats.

MATERIALS AND METHODS Following the approval of Dokuz Eylül University Experimental Animal Research Ethics Committee (2004-24), 40 adult rats weighing 250-300 g whose sensitivity to microorganisms that cause infection in humans were proven in earlier research divided into five groups were used. In Group I: amoxicillinclavulanate (Augmentin BID 400/57 forte oral suspension, SmithKline Beecham, Italy) In Group II: CAM (Klacid oral suspension 125 mg/5 ml, Abbott, Italy), In Group III: cephalexin (Maksipor oral suspension 250 mg/5 ml, Fako, Turkey), In Group IV: levofloxacin, (Avantis Pharma, Germany) and In Group V: normal saline (control group) were given, and animals were fed with standard fodder and water ad libitum. Since there is no oral suspension form of levofloxacin, 500 mg tablets (Avantis Pharma) were made as an oral suspension form with 1% Na-carboxy methyl cellulose and used.

Creation of Wounds Following the ether anesthesia on rats, the hair on their back was shaved off. The surface was cleaned with 70% ethyl-alcohol and 10% povidone-iodine solution. A 2 cm incision was made with no. 15 scalpel from the fourth thoracic vertebra (regio interscapularis) to caudal with paravertebral longitudinal extension reaching fascia, but not including fascia. In order to devitalize wound lips, 1.5 cm wound edges that covered dermoepidermal intersection were clamped for 5 minute with hemostatic clamp.[12,13] 232

Creation of Wound Infection and Closure In order to create wound infection, Staphylococcus aureus ATCC 29213 strain was used. It was vitalized by being incubated in a bloody agar overnight at microbiology laboratory. Bacterial suspension was prepared from reproducing colonies by saline with 108 colony/ml. Devitalized incision line was sutured using three interrupted suture using 4/0 polypropylene. The blood residue on the incision line was cleaned and dried with sterile wet sponge. 0.2 ml bacterial suspension was injected and inoculated into sutured incision line and deep fascia.[1,12-14] In order to provide analgesia, rats were given pethidine hydrochloride (Dolantin, Hoechst Marion Roussel, Germany) 20 mg/kg intramuscularly.[15] The entire wound then was closed with sterile sponge and plastered.

Treatment Four hours after the wound closure, oral antibiotic or placebo treatment was started, and previously-grouped rats were given antibiotics with oral gavage for 5 days.[13] Medication dosage for rats were as follow: cephalexin 60 mg/kg per oral (po) twice a day, amoxicillin-clavulanate 350/50 mg/kg po twice a day, CAM 5 mg/kg po twice a day, levofloxacin 125 mg/kg po once a day.[15,16] Placebo group was given normal saline 1.5 cc with oral gavage twice a day.

Evaluation At the end of day 5, an average of 16-18 hours after the last treatment, rats were evaluated macroscopically and microscopically in terms of wound infection under ether anesthesia. Macroscopic evaluation was conducted in an observational manner by an emergency physician uninformed of the treatment protocol. Incision scars were evaluated with a view to infection findings such as swelling, erythema, induration, purulent flow, and the findings were noted down. For the microscopic evaluation, the scar surface off the suture line was cleaned with 70% ethyl-alcohol and 10% povidone-iodine. After the sutures were removed, wounds were opened with no. 15 scalpel. From every wound, standardized rectangular tissue samples were taken 0.5 cm far from the wound edges containing epidermis, dermis, and subcutaneous tissue. Tissue samples were sent to the microbiology laboratory within 15 minute in petri containers. Each piece was homogenized immediately, and serial dilutions were prepared. By seeding culture into blood agar, bacteria count per gram tissue was calculated, and ≥105 bacteria count per gram tissue was regarded as wound infection.[12]

Statistical Analysis The Statistical Package for the Social Sciences (SPSS Inc., Chicago, Illinois, USA), version 11.0, was used for all statistical analyses. For quantitative bacteria colony counts, first log10 transformation was performed. Chi-square test was used in order to evaluate the effectiveness in the prevention of infection. In all groups, Kruskal–Wallis variance analysis was Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Erbil et al. The effects of oral antibiotics on infection prophylaxis in traumatic wounds

used in the simultaneous evaluation of measurements, Mann– Whitney U-test in the evaluation of dual groups. Significance level was determined as p<0.05.

RESULTS No sign of infection was observed in any of the animals, and no rat was excluded from the experiment. During the macroscopic evaluation performed to detect local findings of the infection, hyperemia in found in two wounds in the placebo group (25%), induration in eight wounds (100%), pus in five wounds (62.5%) were detected. Induration was detected in two wounds in the groups given amoxicillin-clavulanate (25%), in four wounds in the groups given CAM (50%), in six wounds in the groups given cephalexin (75%), in two wounds in the groups given levofloxacin (25%) (Table 1). No difference was observed among the four groups that were treated (Chi-square=5.587, p=0.134). No hyperemia or pus was detected in the groups other than the placebo group (Table 1).

The Effect of Oral Antibiotic Treatment on Groups When the bacteria count of the wounds in amoxicillin-clavulanate, CAM, cephalexin and levofloxacin groups was examined, no difference was observed among the mean bacteria counts of four groups (Kruskal-Wallis p=0.07). No infection

was detected in the four groups treated with antibiotics (Table 2). When the wounds were evaluated in terms of suture areas, hyperemia, induration and pus presence, no significant difference was observed among the groups treated with antibiotics (Chi-square=5.587, p=0.134) (Table 1).

The Comparison of Oral Treatment Options with Placebo When amoxicillin-clavulanate, CAM, cephalexin and levofloxacin groups were compared with the control group in terms of bacterial count, the number of microorganisms in the control group was significantly higher (Mann–Whitney Utest p=0.001) (Table 2). Evaluation in terms of infection rates according to microorganism count per gram tissue, while no infection was detected in amoxicillin-clavulanate, CAM, cephalexin and levofloxacin groups, infection was detected in the seven wounds in control animals (Tables 1 and 2).

DISCUSSION In wound care, applications such as irrigation, debridement, saturation and antibiotics aim to protect the wound from infection and provide functional, esthetic-looking scar.[17] Another method to be used in the prevention of wound infection is prophylactic antibiotics. However, there is no evidence suggesting that prophylactic antibiotics decrease wound in-

Table 1. The distribution of qualitative evaluation parameters according to oral treatment groups

Hyperemia

Enduration

Pus

n % n % n %

Amoxicillin-clavulanate 0 0.0 2 25.0 0 0.0 Clarithromycin

0 0.0 4 50.0 0 0.0

Cephalexin

0 0.0 6 75.0 0 0.0

Levofloxacin

0 0.0 2 25.0 0 0.0

Placebo

2 25.0 8 100.0 5 62.5

Chi-square, (p=0.134).

Table 2. The distribution of quantitative evaluation parameters according to oral treatment groups

Quantitative bacterial count log10±SD

The presence of microbiological infection

n %

Amoxicillin-clavulanate

0.7963±1.48

0 0.0

Clarithromycin

2.3668±1.66

0 0.0

Cephalexin

2.39±1.52

0 0.0

Levofloxacin

0.7813±1.45

0 0.0

Placebo

5.2813±0.77

7 87.5

Kruskal-Wallis variance analysis (p=0.07), Mann-Whitney U-test (p=0.001).

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fection development in patients with traumatic wounds diagnosed at emergency departments.[1,10,11] There is always a long time gap between the initiation of oral prophylactic antibiotics and the occurrence of injury. Therefore, in order to resemble routine applications, treatment was started 4 hours after the inoculation of active organisms into the wound in the present study.[12] In order to prevent wound infection during surgical interventions, application of intravenous prophylactic antibiotics is recommended immediately before or during the procedure. In this way, before the surgical incision is made, high antibiotic concentration will be created in the tissue near the wound. [18,19] However; in traumatic wounds, until the wound evaluation is performed, there is no chance of antibiotic application. Deterioration of perfusion on the incision and occurrence of clot prevent the penetration of antibiotics to the wound rim.[20] As it has been demonstrated in previous animal studies, the effectiveness of prophylactic antibiotics depends on the initiation phase, the earlier is better. However, the effectiveness of oral treatment hasn’t been proven yet.[21] Although S. aureus and group A Streptococcus are responsible for most wound infection, antibiotics to be selected in the atypical wounds, should also be effective on rare pathogens.[20] Since they have antibacterial effectiveness against S. aureus, group A Streptococcus and atypical pathogens depending on the type of the wound, amoxicillin-clavulanate, CAM, cephalexin and levofloxacin are recommended agents.[10,20,22] In this traumatic crushed wound model created on rats infected with S. aureus oral amoxicillin-clavulanate, CAM, cephalexin and levofloxacin application has been proven to be 100% effective in the prevention of wound infection. Berry et al. created a saturated wound model infected with Streptococcus pyogenes and S. aureus in an experimental study on rats in order to compare the effectiveness of gemifloxacin. They demonstrated that gemifloxacin, grepafloxacin, levofloxacin, amoxicillin-clavulanate, cefuroxime and azithromycin given per-orally caused a significant decrease in the number of bacteria compared to the control group.[23] In a double-blind, randomized multi-centric study, Lipsky et al. compared the effectiveness of sparfloxacin and ciprofloxacin in complicated skin infections contracted in the community and 475 patients were given oral sparfloxacin (200 mg once a day following loading dose of 400 mg) and ciprofloxacin (750 g twice a day). In terms of cure and recovery, clinical success rate was found to be 90.1% with sparfloxacin (210/233) and was 87.2% with ciprofloxacin (211/242). Within the subgroups in the study the success rate with infected wounds with the most common complicated skin infection, clinical success rate was found to be 95.7% with sparfloxacin, 96.9% with ciprofloxacin, supporting our study. Bacteriological eradication rate was found to be 87% with sparfloxacin and 79.9% with ciprofloxacin.[24] 234

In another study on experimental skin infection by Gisby and Bryant, oral and topical mupirocin applications were compared on a wound model infected with S. aureus or S. pyogenes on rats similar to ours.[13] Mupirocin and fusidic acid were used in local treatment and erythromycin, cephalexin, floxacillin in systemic treatment. When all the groups treated actively were compared with the control group that wasn’t treated, it was observed that there was an obvious decrease in the average bacteria count. In a double-blind, placebo-controlled clinical study, in order to compare the effectiveness of topical mupirocin and oral cephalexin on secondary infected traumatic wounds (small lacerations, abrasions, or suture wounds), Kraus et al.,[25] gave three doses of topical mupirocin and four doses of oral cephalexin a day. The success rates in the prevention of clinical infection presence in secondary infected traumatic wounds were 95.3% for cephalexin, 95.1% for the groups given mupirocin and the success rate for the microbiological prevention of infection was 98.9% and 96.9%, suggesting similarity to our study on the effectiveness of oral treatment. Furthermore; S. aureus (41%) and S. pyogenes (7%) were the most common isolated microorganisms.[25] Cummings[26] examined eight randomized studies in his meta-analysis on the prevention of infection by antibiotics on patients with dog bite and concluded that prophylactic antibiotic halve infection risk in patients with dog bite injury.

Limitations In most cases, multi-organisms and patients’ existing defense mechanisms play an important role in traumatic wounds infection. But in this study, traumatic wound infection model was created by a single organism.

Conclusion In the traumatic crushed wound model infected with S. aureus in rats, oral prophylactic antibiotics have been found to be effective in the prevention of wound infection. Amoxicillin-clavulanate, CAM, cephalexin and levofloxacin given orally were all found to be 100% effective in the prevention of traumatic wound infection.

Acknowledgement Authors thank to Hatice Giray MD and Bulent Sari MD for their support during the preparation of study. Conflict of interest: None declared.

REFERENCES 1. Hollander JE, Singer AJ, Valentine SM, Shofer FS. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med 2001;8:71620. 2. Lammers RL, Hudson DL, Seaman ME. Prediction of traumatic wound infection with a neural network-derived decision model. Am J Emerg

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Erbil et al. The effects of oral antibiotics on infection prophylaxis in traumatic wounds Med 2003;21:1-7. 3. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med 2008;359:1037-46. 4. Baker MD, Lanuti M. The management and outcome of lacerations in urban children. Ann Emerg Med 1990;19:1001-5. 5. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med 1988;17:496-500. 6. Morgan WJ, Hutchison D, Johnson HM. The delayed treatment of wounds of the hand and forearm under antibiotic cover. Br J Surg 1980;67:140-1. 7. Hollander JE, Singer AJ. Evaluation of wounds. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 ed. New York: McGrawHill Companies; 2010. p. 299-301. 8. Hollander JE, Richman PB, Werblud M, Miller T, Huggler J, Singer AJ. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1998;31:73-7. 9. Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg 2005;189:395-404. 10. Desai S, Stone SC, Carter WA. Wound preparation. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 ed. New York: McGraw-Hill Companies; 2010. p. 301-306. 11. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am 2008;22:117-43. 12. Lammers R, Henry C, Howell J. Bacterial counts in experimental, contaminated crush wounds irrigated with various concentrations of cefazolin and penicillin. Am J Emerg Med 2001;19:1-5. 13. Gisby J, Bryant J. Efficacy of a new cream formulation of mupirocin: comparison with oral and topical agents in experimental skin infections. Antimicrob Agents Chemother 2000;44:255-60. 14. Bergamini TM, Lamont PM, Cheadle WG, Polk HC Jr. Combined topi-

cal and systemic antibiotic prophylaxis in experimental wound infection. Am J Surg 1984;147:753-6. 15. Vital statistics and miscellaneous information. In: Waynforth HB, Flecknell PA, editors. Experimental and surgical technique in the rat. 2 ed. London: Academic Press; 1992 p. 356-7. 16. Shimizu T, Shimizu S, Hattori R, Gabazza EC, Majima Y. In vivo and in vitro effects of macrolide antibiotics on mucus secretion in airway epithelial cells. Am J Respir Crit Care Med 2003;168:581-7. 17. Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990;19:704-8. 18. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-80. 19. Polk HC Jr, Christmas AB. Prophylactic antibiotics in surgery and surgical wound infections. Am Surg 2000;66:105-11. 20. Eron LJ. Targeting lurking pathogens in acute traumatic and chronic wounds. J Emerg Med 1999;17:189-95. 21. Berk WA, Welch RD, Bock BF. Controversial issues in clinical management of the simple wound. Ann Emerg Med 1992;21:72-80. 22. Clinical approach to initial choice of antimicrobial therapy. In: Gilbert DN, Moellering RC, Sande MA, editors. Sanford guide to antimicrobial therapy 2003. 4 ed. USA: Antimicrobial Therapy; 2003. p. 2-45. 23. Berry V, Page R, Satterfield J, Singley C, Straub R, Woodnutt G. Comparative efficacy of gemifloxacin in experimental models of pyelonephritis and wound infection. J Antimicrob Chemother 2000;45 Suppl 1:87-93. 24. Lipsky BA, Miller B, Schwartz R, Henry DC, Nolan T, McCabe A, et al. Sparfloxacin versus ciprofloxacin for the treatment of communityacquired, complicated skin and skin-structure infections. Clin Ther 1999;21:675-90. 25. Kraus SJ, Eron LJ, Bottenfield GW, Drehobl MA, Bushnell WD, Cupo MA. Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected wounds. J Fam Pract 1998;47:429-33. 26. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23:535-40.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik yaralarda oral antibiyotiklerin enfeksiyon profilaksisindeki etkileri Dr. Bülent Erbil,1 Dr. Gürkan Ersoy,2 Dr. Aydan Özkütük,3 Dr. Funda Karbek Akarca,2† Dr. Tanzer Korkmaz,2* Dr. Ömer Faruk Demir,2# Dr. Selahattin Kıyan2† Hacettepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara; Dokuz Eylül Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir; 3 Dokuz Eylül Üniversitesi Tıp Fakültesi, Tıbbi Mikrobiyoloji Anabilim Dalı, İzmir Şimdiki kurumu: †Ege Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir; * İzmir Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir; # Ankara Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara 1 2

AMAÇ: Bu çalışmanın amacı, travmatik yaralarda enfeksiyon gelişiminin önlenmesinde oral antibiyotiklerin etkinliğini incelemektir. GEREÇ VE YÖNTEM: Kırk adet Wistar albino sıçan sekizerli beş gruba ayrıldı. Sıçanların sırtında ezik yara modeli oluşturulduktan sonra, yaralar basit sütür ile kapatıldı. Staphylococcus aureus ATCC 29213 suşları enfeksiyon oluşturulmak için kullanıldı. Kontrol grubu dışındakilere oral gavaj ile beş gün sefaleksin, amoksisilin-klavulanat, klaritromisin ve levofloksasini içeren antibiyotikler verildi. Yaralar, son tedavi verildikten sonra 18. saatinde kalitatif ve kantitatif olarak değerlendirildi. BULGULAR: Kantitatif değerlendirmede amoksisilin-klavulanat, klaritromisin, sefaleksin, levofloksasin ile tedavi edilen gruplarda enfeksiyon tespit edilmedi. Guruplar arasında yaralardaki bakteri sayısı açısından anlamlı fark bulunmadı. Kantitatif enflamasyon bulgularına göre değerlendirildiğinde, medikasyon uygulanan dört grubun hiçbirinde hiperemi ve püy belirlenmedi. Endürasyon açısından gruplar arasında anlamlı fark bulunmadı. TARTIŞMA: Sıçanlarda Staphylococcus aureus ile oluşturduğumuz enfekte travmatik ezik yara modelinde; oral proflaktik antibiyotiklerin yara enfeksiyonunu önlemede etkin olduğu bulunmuştur. Anahtar sözcükler: Antibiyotik; profilaksi; travmatik yara; yara enfeksiyonu. Ulus Travma Acil Cerrahi Derg 2014;20(4):231-235

doi: 10.5505/tjtes.2014.63993

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ORIGINAL ARTICLE

Correlation between arterial blood gas analysis and outcome in patients with severe head trauma Amirmohammad Bazzazi, M.D.,1 Mohammad Amin Valizade Hasanloei, M.D.,2 Alireza Mahoori, M.D.,2 Mahdia Gholamnejad, M.D.,3 Habibeh Tarverdipour, M.D.4 1

Department of Neurosurgery, Urmia University of Medical Sciences, Urmia, Iran;

Department of Anesthesiology, Urmia University of Medical Sciences, Urmia, Iran;

Department of Pulmonary Medicine, Urmia University of Medical Sciences, Urmia, Iran;

Urmia University of Medical Sciences, Urmia, Iran

ABSTRACT BACKGROUND: Traumatic brain injury is one of the major concerns of global public health, because it is the main cause of morbidity and mortality between young people. This study aimed to investigate the possible association between the parameters of arterial blood gas (ABG) and outcome of patients with severe head trauma. METHODS: In this prospective study, 70 patients with severe head trauma were studied in Urmia Imam Khomeini hospital during 18-month period of time. The parameters of ABG were documented within the 1st hour of admission, and their correlation was evaluated with Glasgow coma scale (GCS) and Glasgow outcome score (GOS). These parameters also were compared between expired and discharged patients. RESULTS: Seventy patients with severe head trauma including 60 males (85.7%) and 10 females (14.3%) with a mean age of 34.34Âą14.82 (range: 18-76) years were studied. The mortality rate during hospitalization was 38.6% (n=27). There was no significant correlation between the parameters of ABG and GCS score and GOS scores. Furthermore, there was no significant difference between the survivors and non-survivors in terms of the mean value of ABG parameters (p>0.05). CONCLUSION: ABG at the time of admission is not a significant predictor of outcome in patients with severe head trauma. Key words: Arterial blood gas; outcome; severe head trauma.

INTRODUCTION Traumatic brain injury is a major problem all over the world, because it is the main cause of death in the young population. Since traffic accidents constitute the most frequent underlying etiology of head trauma, the incidence of traumatic brain injury is expected to increase. It is anticipated that traumatic brain injury would be the leading cause of death and disability in 2020.[1,2] The primary injury is due to direct mechanical

Address for correspondence: Mohammad Amin Valizade Hasanloei, M.D. Ershad Ave. Emam Hospital, Urmia, Iran Tel: 984413457286 E-mail: aminvalizade@yahoo.com Qucik Response Code

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damage and the secondary damage (delayed non-mechanical) is induced by changes in cerebral blood flow (such as hypoand hyper-perfusion), inadequate cerebral oxygenation, and impairment of cerebrovascular auto-regulation, cerebral metabolic dysfunction, excitotoxic cell damage, and inflammation. While the primary damage could not be therapeutically influenced, treatment should be focused on the secondary damage.[3,4] The identification of reliable predictors of outcome after head injury is essential to appropriate counseling of family members and employing resources. Some authors believe that arterial PCO2 at the time of admission is a significant prognostic factor in patients with traumatic head injury,[5] whereas others have denied the parameters of arterial blood gas (ABG) as reliable indicators of short term outcome in these patients.[6] The present prospective study aimed to investigate a possible association between the parameters of ABG and outcome in patients with severe head injury.

MATERIALS AND METHODS After being approved by the Ethics Committee of Urmia UniUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Bazzazi et al. Correlation between arterial blood gas analysis and outcome in patients with severe head trauma

versity of Medical Sciences, this prospective cross-sectional study was performed in intensive care unit and emergency department of Urmia Imam Khomeini Teaching Hospital during 18 months period of time (January 2012 to July 2013). Written informed consents were obtained from patients’ accompanying family members/guardian prior to enrollment. Patients younger than 18 and older than 80 years, with severe trauma to the thoracic/abdominal regions, requiring operation on the brain, thoracic region, or abdomen, hospital stay <24 hours, and with chronic obstructive pulmonary disease were excluded from the study. Finally, 70 patients with severe head trauma Glasgow coma scale (GCS ≤8) were included in the study. All the patients were thoroughly examined by an experienced neurosurgeon at the time of admission and regularly during the hospital stay and were managed similarly during hospitalization. Severity of head trauma was accessed by GCS score on admission, 24 hours, 48 hours, and 1 week later, and at discharge. Glasgow outcome score (GOS) was also calculated in the discharged cases. The parameters of ABG including acidity (pH), O2 and CO2 pressure (PO2 and PCO2, respectively), bicarbonate (HCO3), and O2 saturation (O2Sat) were determined within 4 hours of admission.

Statistical Analysis Data were expressed as mean ± standard deviation and were analyzed by independent t-test and Pearson’s correlation coefficient (r) among two groups using SPSS statistical software Table 1. Final diagnoses in the studied patients with severe head trauma

version 16 (Chicago, IL, USA). p<0.05 was considered as statistically significant.

RESULTS Seventy patients with severe head trauma, including 60 males (85.7%) and 10 females (14.3%) with a mean age of 34.34±14.82 (range: 18-76) years were included in the study. The mechanism of trauma was a traffic accident in 59 cases (84.3%), falling in eight cases (11.4%), and physical assault in three cases (4.3%). Final diagnoses in the studied group of patients are summarized in Table 1. Laboratory findings, ABG, GCS, and GOS at the time of admission and during hospitalization are summarized in Table 2. The duration of hospital stay was 17.31±16.26 days. Fortythree patients (61.4%) were discharged from the hospital and 27 patients (38.6%) expired. Table 2. Laboratory findings, ABG, GCS, and GOS in the patients with severe head trauma at the time of admission and during hospital stay Variable

Mean±standard deviation (range)

Serum parameters (admission)

Glucose (mg/dL)

186.15±70.25 (94-376)

Blood urea nitrogen (mg/dL)

35.17±14.56 (20-120)

Potassium (mEq/dL)

Sodium (mEq/dL)

143.97±4.79 (135-170)

Hemoglobin (mg/dL)

12.55±2.51 (7.5-19.2)

Creatinine (mg/dL)

Prothrombin time (seconds)

Partial thromboplastin

4.46±3.66 (0.8-6.3)

1.00±0.29 (1-2) 14.31±2.12 (13-24) 34.36±13.68 (23-130)

Diagnosis

n %

time (seconds)

Diffuse axonal injury

42.9

International normalized ratio

Subdural hemorrhage

18.6

Arterial blood gas (admission)

Contusion

7 10

7.26±0.59

Subdural hemorrhage + contusion

5.7

PCO2 (mmHg)

34.63±8.43

EDH

3 4.3

HCO3 (mEq/L)

18.71±4.29

Subarachnoid hemorrhage + contusion

2.9

PO2 (mmHg)

IVH + contusion

2.9

O2Sat (%)

IVH

2 2.9

Glasgow coma scale score

Subdural hemorrhage + ICH

2.9

At admission

1.30±0.45 (1-3)

118.98±54.79 94.63±6.78 6.27±1.55 (3-8)

Subarachnoid hemorrhage

1.4

24 hours

6.52±1.75 (3-11)

IVH + Subarachnoid hemorrhage + contusion

1.4

48 hours

6.75±2.33 (3-14)

EDH + Subarachnoid hemorrhage + contusion

1.4

1 week

8.50±3.10 (3-15)

EDH + contusion

1.4

At discharge

8.71±5.23 (3-15)

Subdural hemorrhage + SAH

1.4

Glasgow outcome scale

2.70±1.64 (1-5)

EDH: Epidural hemorrhage; ICH: Intracerebral hemorrhage; IVH: Intraventricular hemorrhage.

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GCS: Glasgow coma scale; ABG: Arterial blood gas; GOS: Glasgow outcome score.

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Bazzazi et al. Correlation between arterial blood gas analysis and outcome in patients with severe head trauma

Correlation between the parameters of ABG at the time of admission with GCS score and GOS are summarized in Table 3. Accordingly, there was no significant correlation between the mentioned parameters. Mean parameters of ABG are compared between the expired and discharged patients as shown in Table 4. According to this table, there was no significant difference between the two groups in terms of ABG parameters (p>0.05).

the world. In severe trauma, the mortality rate can reach up to 50%. This rate has fallen from 80% in 1950 to 20% over recent years. The mortality rate in the present work was 38.6%, which seems to be average of the reported value by various articles.[7]

DISCUSSION

Since the management and used medications in our patients are similar to those in more developed countries, higher rate of mortality seems to be due to more severe injuries, possibly because of lower traffic standards and unsafe vehicles. Thus, the most useful way to diminish traumatic head injuries and their consequences is the prevention.[1]

Traumatic brain injury is the leading cause of death and longtime disability in the young (<40 years) individuals all over

The mean age of our patients was 34.34±14.82 (range: 18-76) years and the males were included the (85.7%) of patients.

Table 3. Correlation between the parameters of ABG at the time of admission with GCS score (at different intervals) and GOS Parameters GCS GOS

24 hour

48 hour

1 week

Discharge

pH r

0.01

0.93 0.80 0.75 0.71 0.92

0.03

0.04

−0.04

0.01

PCO2 r

−0.09

−0.11

0.15

−0.03

0.43 0.32 0.26 0.80 0.75

HCO3 r

0.14 0.13 0.22 0.16 0.16

0.24 0.25 0.09 0.18 0.17

PO2 r

−0.05

−0.02

0.06

0.15

0.96 0.88 0.64 0.21 0.20

O2Sat r

−0.09 0.01 0.12 0.17 0.16

0.45 0.95 0.38 0.14 0.17

GCS: Glasgow coma scale; ABG: Arterial blood gas; GOS: Glasgow outcome score.

Table 4. Parameters of arterial blood gas in expired and discharged patients with severe head trauma Parameter

Expired (n=27)

Discharged (n=43)

Mean±SD Mean±SD

7.30±0.13

7.24±0.75 0.68

PCO2 (mmHg)

35.94±9.69

33.80±7.50

0.30

HCO3 (mEq/L) PO2 (mmHg) O2Sat (%)

17.88±4.06

19.24±4.39

0.19

104.62±46.06

128.00±58.33

0.08

92.88±7.82

95.75±5.82

0.08

SD: Standard deviation.

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These findings are in line with similar reports.[8,9] Dumont et al.[5] studied 65 patients with traumatic brain injury in a retrospective manner to determine the effect of prehospital hyperventilation on in-hospital mortality. According to their findings, survival was related to admission PCO2 in patients requiring intubation. The survival rate in patients with normocarbia was significantly better than that in cases with either hypo- or hyper-carbia. In contrast, the mentioned study, there was not a significant association between admission PCO2 and prognosis in our patients. It should be noted that in Dumont’s series, ABG was performed within 20 minutes of admission, whereas in the present study ABG assessment was carried out within 4 hours after trauma, when the patients were resuscitated, clinical stability was achieved, and received mechanical ventilation, if necessary. Pfenninger and Lindner[10] also showed that while the parameters of ABG analysis at the accident site were predictive of the status of patients with head trauma, after intubation and controlled ventilation, the hypercapnia of the comatose patients had been corrected, and a correlation could no longer be found between the levels of GCS score and PaCO2. The admission PO2 was not significantly correlated with GCS score or GOS in our patients. However, the mean PO2 was higher, although marginally insignificant, in the survived patients comparing with those who expired (128.00±58.33 mmHg vs. 104.62±46.06 mmHg; p=0.08). Similar trend was documented for O2 sat (95.75±5.82% vs. 92.88±7.82%; p=0.08). Valadka et al.[11] determined thresholds of brain tissue PO2 that are critical for survival after severe head trauma. Based on their findings, the mortality rate increased with increasing duration of time at or below a PO2 of 15 torr or with the occurrence of any PO2 values of ≤6 torr. These findings lay emphasis on the importance of PO2 and O2Sat in patients with severe head trauma. Kushi et al.[12] suggested that jugular venous pH (after the patients stabilized) was useful as an early prognostic indicator in the maintenance of neurological function in patients with traumatic head injury. We were not able to confirm similar role for arterial pH. In a study by Henzler et al.[6] the parameters of ABG on admission and during hospitalization were compared between head trauma survivors and non-survivors. They showed that PCO2 was similarly elevated in both groups on arrival in the emergency department, reflecting inadequate ventilation.

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However, normalization of PCO2 was quicker in survivors than non-survivors. Patients in both groups had a mild metabolic acidosis on admission, which had normalized by 12 h. PaO2 was non-significantly higher in survivors up until 4 hour after the trauma. Overall, the parameters of ABG were not significant predictors of survival in traumatic patients with head injury in this series. Our findings are in conformity with the results of this study. It seems that changes in the parameters of ABG may reflect a better indicator of prognosis than their values only after admission. Further studies are recommended in this regard. Based on our findings although PO2 and O2Sat may be associated with better prognosis in head trauma injury, the parameters of ABG on arrival of patients in the emergency department are not possibly of prognostic value. Conflict of interest: None declared.

REFERENCES 1. Winn RH. Youmans neurological surgery. 6th ed. Saunders; 2011. p. 3270-506. 2. Lopez AD, Murray CC. The global burden of disease, 1990-2020. Nat Med 1998;4:1241-3. 3. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4. 4. Werner C, Engelhard K. Pathophysiology of traumatic brain injury. Br J Anaesth 2007;99:4-9. 5. Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma 2010;27:1233-41. 6. Henzler D, Cooper DJ, Mason K. Factors contributing to fatal outcome of traumatic brain injury: a pilot case control study. Crit Care Resusc 2001;3:153-7. 7. Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC, Manley GT, Gruen RL. Early management of severe traumatic brain injury. Lancet 2012;380:1088-98. 8. Helm M, Hauke J, Lampl L. A prospective study of the quality of prehospital emergency ventilation in patients with severe head injury. Br J Anaesth 2002;88:345-9. 9. Salehpoor F, Bazzazi AM, Estakhri R, Zaheri M, Asghari B. Correlation between catecholamine levels and outcome in patients with severe head trauma. Pak J Biol Sci 2010;13:738-42. 10. Pfenninger EG, Lindner KH. Arterial blood gases in patients with acute head injury at the accident site and upon hospital admission. Acta Anaesthesiol Scand 1991;35:148-52. 11. Valadka AB, Gopinath SP, Contant CF, Uzura M, Robertson CS. Relationship of brain tissue PO2 to outcome after severe head injury. Crit Care Med 1998;26:1576-81. 12. Kushi H, Moriya T, Saito T, Kinoshita K, Shibuya T, Hayashi N. Importance of metabolic monitoring systems as an early prognostic indicator in severe head injured patients. Acta Neurochir Suppl 1999;75:67-8.

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KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Ciddi kafa travması olan hastalarda sonlanımla arter kan gazı analizi arasındaki korelasyon Dr. Amirmohammad Bazzazi,1 Dr. Mohammad Amin Valizade Hasanloei,2 Dr. Alireza Mahoori,2 Dr. Mahdia Gholamnejad,3 Dr. Habibeh Tarverdipour4 Urmia Üniversitesi Tıp Bilimleri, Nöroşirürji Anabilim Dalı, Urmia, İran Urmia Üniversitesi Tıp Bilimleri, Anesteziyoloji Anabilim Dalı, Urmia, İran Urmia Üniversitesi Tıp Bilimleri, Göğüs Hastalıkları Anabilim Dalı, Urmia, İran 4 Urmia Üniversitesi Tıp Bilimleri, Urmia, İran 1 2 3

AMAÇ: Genç kişilerde morbidite ve mortalitenin başlıca nedeni olduğu için travmatik beyin hasarı global halk sağlığının başlıca kaygılarından biridir. Bu çalışmada, arter kan gazı (AKG) parametreleriyle ağır kafa travması geçirmiş hastaların sonlanımı arasındaki olası ilişki araştırıldı. GEREÇ VE YÖNTEM: Bu ileriye yönelik çalışmada 18 aylık dönem boyunca ağır kafa travmalı 70 hasta Urmia İmam Hümeyni Hastanesi’nde incelendi. Hastaneye kabulden sonraki bir saat içinde AKG parametreleri kaydedildi ve Glasgow koma skalası (GKS) ve Glasgow sonuç skoru (GSS) ile korelasyonları değerlendirildi. Bu parametreler ölen ve taburcu edilen hastalar arasında da karşılaştırıldı. BULGULAR: Altmışı erkek (%85.7) ve 10’u (%14.3) kadın olmak üzere kafa travmalı ve yaş ortalaması 34.34±14.82 (erimi: 18-76) yıl olan 70 hasta incelendi. Hastanede yatış sırasında ölüm oranı %38.6 (n=27) idi. AKG parametreleri, GKS skoru ve GSS skorları arasında anlamlı bir korelasyon yoktu. Ayrıca, ortalama AKG parametreleri açısından sağ kalanlarla hayatını kaybedenler arasında herhangi bir anlamlı farklılık yoktu (p>0.05). TARTIŞMA: Hastaneye kabulde ölçülen AKG ağır kafa travmalı hastalardaki sonlanımın anlamlı bir öngördürücü faktörü değildir. Anahtar sözcükler: Ağır kafa travması; arter kan gazı; sonlanım. Ulus Travma Acil Cerrahi Derg 2014;20(4):236-240

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doi: 10.5505/tjtes.2014.57089

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ORIGIN A L A R T IC L E

Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department Erhan Ahun, M.D.,1 Özlem Köksal, M.D.,1 Deniz Sığırlı, M.D.,2 Gökhan Torun, M.D.,1 Serdar Suha Dönmez, M.D.,1 Erol Armağan, M.D.1 1

Department of Emergency Medicine, Uludag University Faculty of Medicine, Bursa;

Department of Biostatistics, Uludag University Faculty of Medicine, Bursa

ABSTRACT BACKGROUND: The purpose of this study is to detect the mortality predictive power of new Glasgow coma scale, age, and arterial pressure (GAP) scoring system in major trauma patients admitted to the emergency department (ED). METHODS: A total of 100 major trauma patients admitted to Uludağ University Faculty of Medicine ED who were 18 years of age or more were included in the study. In this prospective study, revised trauma score (RTS), injury severity score (ISS), trauma-related ISS (TRISS), Mechanism, GAP (MGAP) and GAP scores of the patients were calculated. RESULTS: A significant positive correlation was established between ISS, TRISS, MGAP, and GAP in predicting in-hospital mortality (p<0.0001). Short-term (24 hours) and long-term (4-week) mortality prediction rates and area under the curve in receiver operating characteristics analysis were 0.727-0.680 for RTS, 0.863-0.816 for ISS, 0.945-0,911 for TRISS, 0.970-0.938 for MGAP, and 0.910-0.904 for GAP. All calculated trauma scoring systems revealed a significant mortality prediction power (p<0.001). GAP score was found statistically and significantly selective and sensitive in predicting both in-ED and in-hospital mortality (p=0.0001). CONCLUSION: In major trauma patients, GAP score is an easily calculable system both in the field and at the time of admission in the EDs by providing emergency physicians with future decision-making schemes by means of mortality prediction of the patients. Key words: Major trauma; mortality; trauma scoring systems.

INTRODUCTION Trauma is a serious problem worldwide, particularly affecting the young. Accordingly, trauma results in production loss in addition to being a health problem. It is also the leading cause of death in people from 1 to 44 years of age, while it is in the third leading cause for all age groups, following cancer and Address for correspondence: Özlem Köksal, M.D. Uludağ Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Görükle Yerleşkesi, 16059 Bursa, Turkey Tel: +90 224 - 295 32 22 E-mail: koksalozlem@gmail.com Qucik Response Code

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cardiovascular diseases.[1] Previous studies have demonstrated that 25-50% of deaths due to trauma are preventable.[2] Trauma scoring systems (TSSs) have been used for nearly four decades to determine the type and severity of trauma and predict the prognosis of trauma patients with an increased mortality rate.[3] The practical use of some current TSSs is somewhat restricted in terms of calculation difficulty and the requirement of laboratory data for scoring. The Glasgow coma scale (GCS)age-systolic blood pressure (SBP) (GAP) score is a physiological trauma scoring system defined in a study by Kondo et al.[4] It is remarkable due to the requirement of fewer parameters, its applicability in the field, and mortality predictive power very similar to the trauma-related injury severity score (TRISS).[4] The GAP score is easily calculable both in the field and at the time of admission to the emergency department (ED). 241

Ahun et al. The mortality of major trauma patients presenting to the emergency department

The purpose of this study was to detect the mortality predictive power of a new GAP scoring system for major trauma patients admitted to the ED. We therefore compared the revised trauma score (RTS), the ISS, TRISS, and the mechanism, GAP (MGAP) scores.

MATERIALS AND METHODS

variables mean±standard deviation were given as descriptive statistics; otherwise median (minimum-maximum) values were given. Mann–Whitney U-test was used to compare two independent groups. Fisher’s exact test was used to compare categorical variables and n and percentage values were given as descriptive statistics. Receiver operating characteristics

Following a physical examination, a total of 100 major trauma patients admitted to the Uludag University Faculty of Medicine ED who were 18 years of age or older were included in the study (Ethic Board number: 2012-13/9). Pregnant patients and those with psychiatric illnesses were excluded. Demographic data (age, gender), type of arrival, GCS, blood pressure, oxygen saturation, respiration rate, injury mechanism, vital signs, anatomic sites of injury, alcohol intake, prescribed treatments, required consultations, final outcome (hospitalization, transfer, discharge, treatment rejection, and exitus), and unit of hospitalization (clinic, intensive care unit [ICU]) were recorded.

Table 2. Characteristics of the trauma patients

Using the phone numbers and addresses recorded at the time of admission, the patients were contacted and followed up during a 4-week period to calculate the short-term (24 hours) and long-term (4-week) mortality prediction rates. The RTS, ISS, TRISS, MGAP, and GAP scores were calculated by evaluating the patient data, laboratory data, and radiologic imaging and consultation results recorded in the data processing system. The prediction of mortality by TSS was classified as low risk (<5%), intermediate risk (5-50%) and high risk (>50%). The patient RTS, ISS, and TRISS were obtained using a score calculator available at www.trauma.org. For the MGAP and GAP scores, the point scoring systems reported by Sartorius et al.[5] and Kondo et al. were used, respectively[4] (Table 1).

Ambulance

99 99

Statistical analyses were performed with IBM SPSS Statistics 21.0 and MedCalc 12.2.1.0. Normality of the variables was tested with the Shapiro–Wilk test. For normally distributed

Table 1. GAP scoring system

3-15

3-15 points

Age

<60

3 points

>60

0 point

Systolic blood pressure (mmHg)

>120

6 points

60-120

4 points

<60

0 point

GAP: Glasgow coma scale, age, and arterial pressure; GCS: Glasgow coma scale.

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n % Mean±SD

Age (years)

40.35±16.11

Gender Male

77 77

Female

23 23

Arrival

From scene

By transfer

Type of transport Private vehicle

Type of injury Blunt

98 98

Penetrating

2 2

Mechanism

In-vehicle traffic accident

Extravehicular traffic accident

Falling from a height

Motorbike accident

Injury by firearms

Sharp object injuries

Injured area Head-neck

55 55

Face

19 19

Chest

57 57

Abdomen

18 18

Extremity

70 70

Other

2 2

Vital signs

GCS

Pulse (per min)

90.99±17.57

SBP (mmHg)

119.60±18.58

DBP (mmHg)

75.50±10.09

Respiratory rate (per minute)

17.19±3.22

Temperature (°C)

36.25±0.36

SpO2 95.57±4.78

Glasgow coma score*

Alcohol intoxication

15 (3-15)

SBP: Systolic blood pressure; DBP: Diastolic blood pressure; *Data were given as median (minimum-maximum).

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Ahun et al. The mortality of major trauma patients presenting to the emergency department

(ROC) curve analysis was performed to evaluate and compare the performances of the scores. The statistical significance level was Îą=0.05.

RESULTS The mean patient age was 40.35Âą16.11 (min: 18 - max: 90) years and 77% were male. Blunt injury accounted for 98% of the injuries. The most frequent causes of presentation were in-vehicle traffic accident (68%) and falling from a height (13%). The most common injured body parts were the extremities (70%), followed by the chest (57%). Other characteristics of the trauma patients are shown in Table 2. Of the major trauma patients, 36% were hospitalized in the ICU, and 36% were hospitalized in the clinic. The mortality rate in the ED was 3%, and it was similar in the ICU and operating room (OR) within 24 hours, at 3%, while the mortality rate within 4-week was 6%. The mortality rate of all patients included in the study was 12%.

Trauma scoring systems (RTS, ISS, TRISS, and MGAP) were used to classify patients as having a low risk (<5%), intermediate risk, or high risk (>50%) of death. Two patients who were evaluated as intermediate risk by the RTS were classified as low risk by the GAP score, while 1 patient evaluated as low risk by the RTS was classified as intermediate risk by the GAP. In addition, 1 of 2 patients classified as high risk by the MGAP was classified as intermediate risk by the GAP, and 2 patients classified as low risk by the MGAP were classified as intermediate risk by the GAP. Five patients classified as intermediate risk by the GAP were reclassified as low risk by the MGAP. Five of 14 patients classified as high risk by the ISS were classified as intermediate risk by the GAP, while the GAP considered 8 of them low-risk. In addition, 20 of 24 patients classified as intermediate risk were evaluated as low risk, and 2 patients evaluated as low risk by the ISS were classified as intermediate risk. Four of 15 patients classified as intermediate risk by the TRISS were classified as low risk by the GAP. In the study by Kondo et al., patient classifications by the scoring systems were similarly reclassified by the GAP

Table 3. The comparison of GAP scores with the RTS, ISS, TRISS and MGAP score for mortality prediction groups Score

Revised trauma score

Severity

Severe (<3.4 points)

Moderate (3.4 to 7.2 points)

Mild (>7.2 points)

Total

GAP

Severe (3-10 points)

Moderate (11-18 points)

Mild (19-24 points)

100

Total Score MGAP

Severity

Severe (3-14 points)

Moderate (15-22 points)

Mild (23-29 points)

Total

GAP

Severe (3-10 points)

Moderate (11-18 points)

Mild (19-24 points)

100

Total Score ISS

Severity

Severe (>25 points)

Moderate (16-25 points)

Mild (<16 points)

Total

GAP

Severe (3-10 points)

Moderate (11-18 points)

Mild (19-24 points)

100

Total Score TRISS

Severity

Severe (>25 points)

Moderate (16-25 points)

Mild (<16 points)

Total

GAP

Severe (3-10 points)

Moderate (11-18 points)

Mild (19-24 points)

100

Total

ISS: Injury severity score; GAP: Glasgow coma scale, age, and arterial pressure; TRISS: Trauma-related injury severity score; MGAP: Mechanism, Glasgow coma scale, age, and arterial pressure.

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Ahun et al. The mortality of major trauma patients presenting to the emergency department

Table 4. Characteristics of survivors versus non-survivors for 4-week mortality Characteristics

Survivors (n=88)

Non-survivors (n=12)

Gender n (%) 66 (85.71)

0.286

Male

Female

22 (95.65)

1 (4.35)

Age (years)

35 (18-90)

52.50 (18-78)

0.023

Systolic pressure

120 (90-160)

115 (70-160)

0.414

Diastolic pressure

80 (60-100)

70 (40-90)

0.176

Pulse rate

88 (56-132)

105 (52-140)

0.019

Respiratory rate

16 (12-25)

19 (9-30)

0.097

Temperature

36.0 (36-38.2)

36 (36-36.7)

0.722

O2 saturation

97.5 (83-99)

92 (70-99)

0.008

15 (6-15)

13 (3-15)

<0.001

7.84 (5.97-7.84)

7.84 (3.36-7.84)

0.001

Glasgow coma scale Revised trauma score* Injury severity score

11 (14.29)

10 (1-43)

24 (9-48)

<0.001

99.2 (68.7-99.7)

90 (14.9-98.8)

<0.001

Mechanism, Glasgow coma scale, age, and arterial pressure

27 (18-29)

22 (15-25)

<0.001

Glasgow coma scale, age, and arterial pressure

22 (13-24)

18 (9-22)

<0.001

Trauma-related injury severity score

Data are presented as n (%) or median (minimum-maximum). *Mean±standard deviation for survivals are 7.71±0.43 and for non-survivals are 6.49±1.82.

score.[4] The distribution of patients by the TSSs and their reclassification by the GAP are displayed in Table 3.

0.910 (p<0.001) for GAP respectively, in predicting 24-hour mortality (Table 5, Fig. 1).

While RTS, TRISS, MGAP, and GAP values were significantly higher among 4-week survivors than among non-survivors; ISS values were significantly lower among 4-week survivors than among non-survivors. Furthermore, there was a significant difference between the survivals and non-survivals in terms of age, pulse rate, oxygen saturation, and GCS (Table 4).

Furthermore, AUCs were found to be 0.680 (p=0.026) for RTS, 0.816 (p<0.001) for ISS, 0.911 (p<0.001) for TRISS, 0.938 (p<0.001) for MGAP and 0.904 (p<0.001) for GAP respectively, in predicting 4-week mortality (Table 6, Fig. 2).

ROC analyses were performed to examine the performances of RTS, ISS, TRISS, MGAP, and GAP in predicting 24-hour and 4-week mortality. The area under the curves (AUCs) were found to be 0.727 (p=0.012) for RTS, 0.863 (p<0.001) for ISS, 0.945 (p<0.001) for TRISS, 0.970 (p<0.001) for MGAP and

The performance of MGAP in predicting 4-week mortality was significantly higher than RTS (p<0.001) and ISS (p=0.039); but there was no significant difference between the performance of MGAP was not significantly from the GAP (p=0.177) and from the TRISS (p=0.293). The performance of GAP and TRISS were significantly higher from the RTS (p<0.001 and p=0.001).

Table 5. Predictive values of the scores in the prediction of the 24 hours mortality

Cut-off value

Sensitivity (%) (95% CI)

Specificity (%) (95% CI)

AUC

Revised trauma score

5.68

50.00 (12.4-87.6)

100.00 (95.9-100.0)

0.727

0.012

Injury severity score

83.33 (36.1-97.2)

73.86 (63.4-82.7)

0.863

<0.001

Glasgow coma scale, age,

83.33 (36.1-97.2)

87.50 (78.7-93.6)

0.910

<0.001

95.4

100.00 (54.1-100.0)

87.50 (78.7-93.6)

0.945

<0.001

100.00 (54.1-100.0)

89.77 (81.5-95.2)

0.970

<0.001

and arterial pressure Trauma-related injury severity score Mechanism, Glasgow coma scale, age, and arterial pressure CI: Confidence interval; AUC: Area under the curve.

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Table 6. Predictive values of the scores in the prediction of the 4-week mortality

Cut-off value

Sensitivity (%) (95% CI)

Specificity (%) (95% CI)

AUC

Revised trauma score

5.97

41.67 (15.2-72.3)

95.45 (88.8-98.7)

0.680

0.026

Injury severity score

83.33 (51.6-97.9)

67.05 (56.2-76.7)

0.816

<0.001

Glasgow coma scale, age, and

91.67 (61.5-99.8)

78.41 (68.4-86.5)

0.904

<0.001

arterial pressure Trauma-related injury severity score Mechanism, Glasgow coma scale,

96.8

91.67 (61.5-99.8)

80.68 (70.9-88.3)

0.911

<0.001

100.00 (73.5-100.0)

80.68 (70.9-88.3)

0.938

<0.001

age, and arterial pressure CI: Confidence interval; AUC: Area under the curve.

DISCUSSION Trauma scoring systems are commonly used for prognosis and determining the severity of a patient’s condition in the early stage of treatment. The TRISS is one of the most widely used TSSs, and it strongly predicts the probability of survival. [6,7] The GAP, which is one of the physiological scoring systems, is easy to use and fast to calculate and provides efficient treatment by determining the trauma severity in the early stages. This study aimed to evaluate the predictive prognostic power of the GAP scoring system for major trauma patients and its applicability in the ED by comparing it with the RTS, ISS, TRISS, and the MGAP scores. TSSs are valuable for facilitating communication between healthcare professionals and allowing a consistent common

language in investigations. Studies performed using similar measurements can be reliably compared.[8-10] The literature indicates that trauma-related deaths are usually divided into three groups. Group 1 (50%) includes those who die at the scene, and they are usually patients with major head trauma or severe vascular injury. Group 2 (30%) includes those who are admitted to the hospital and die within the first several hours, a period termed the “golden hour.” These injuries often include major head, thorax, and abdominal trauma. Group 3 (20%) consists of patients who die at a later time, for example in an ICU. The deaths in this group are typically due to sepsis or multi-organ failure.[11] The mortality of patients in Groups 2 and 3 can be prevented through fast and accurate treatment methods. Accordingly, a TSS that is easy and efficient to use may help prevent mortality. Scoring systems are bedside methods for identifying patients with catastrophic

Sensitivity

100

Sensitivity

100

GAP ISS MGAP RTS TRISS

0 0

100

100-Specificity

Figure 1. Receiver operating characteristics curves for the Glasgow coma scale, age, and arterial pressure (GAP), mechanism GAP, injury severity score, trauma-related injury severity score, and revised trauma score for short-term mortality prediction.

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GAP ISS MGAP RTS TRISS

0 0

100

100-Specificity

Figure 2. Receiver operating characteristics curves for the Glasgow coma scale, age, and arterial pressure (GAP), mechanism GAP, injury severity score, trauma-related injury severity score, and revised trauma score for long-term mortality prediction.

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Ahun et al. The mortality of major trauma patients presenting to the emergency department

deterioration risk by identifying abnormalities.[12] The ISS and the TRISS are widely accepted TSSs, and their calculation requires that all examinations and workups are performed and that injuries in anatomic locations are noted in a detailed manner. The accurate determination of the seriousness of the condition on the part of patient is only possible through accurate identification of the injury. Both methods require time. It is suggested that the ISS and the TRISS should be calculated 24 hours following patient admission.[13] Within the first several hours, termed the “golden hour,” for a majority of patients presenting with major trauma, the ISS and the TRISS cannot be calculated, which handicaps their roles in guiding treatment. The prediction of prognosis is impossible at the time of ED admission using these TSSs. As the ISS and the TRISS require information not readily available at the time of presentation to the ED, they cannot provide early warning information on trauma severity for ED physicians. Guenther et al.[14] reported a mean in-hospital mortality rate of 26.2%. The mortality rates in other studies available in the literature vary from 9% to 18.3%.[4,5,8,15] Similarly, the mortality rate in our study was 12%. In the majority of trauma patients, serious injuries and mortality risk might be identified by considering physiological parameters at the scene.[7] With this purpose, various TSSs have been developed. One of the best known is the RTS, but its adoption is limited due to the difficulty in its calculation. [8,9,13] Sartorius et al.[5] developed the MGAP score as an improvement over the previous simple trauma scores in a largescale study in France, and the predicted mortality rates were similar between the RTS and the TRISS. We found a significant difference between the RTS and the MGAP in favor of the MGAP and between the ISS and the MGAP in favor of the MGAP; however, no significant difference was found between the GAP and the MGAP. The GAP is a physiological trauma scoring system defined by Kondo et al. in a multicenter study carried out in Japan. Patient age, GCS, and SBP are sufficient for calculating the score. Kondo et al. reported correlations in the abilities of the GAP and the RTS as well as the TRISS and the MGAP to predict mortality. While the TRISS showed better predictive results, the GAP score provided the closest predictive results to those of the TRISS.[4] In our study, the GAP score results were similar to the results of the TRISS, and no statistically significant difference was observed between them. However, a statistically significant difference was observed between the GAP and the RTS in favor of the GAP.

Conclusion Because the GAP score is easier to calculate and has few parameters, it is advantageous for providing fast results, al-

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lowing quick decision making. In major trauma patients, we believe that the GAP score is an easily calculable system both in the field and at the time of admission to the ED that can suggest future decision-making schemes to ED physicians by predicting patient mortality. In addition, it is a simple scoring system that can guide healthcare staff at the scene and enable the transfer of trauma patients to trauma centers, which may reduce the loss of time. Conflict of interest: None declared.

REFERENCES 1. Hunt RC, Krohmer JR. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Program for Doctors. 7th ed, 2004. p. 1-10. 2. Lewis FR. Initial assessment and resuscitation. Emerg Med Clin North Am 1984;2:733-48. 3. Kirkpatrick JR, Youmans RL. Trauma index. An aide in the evaluation of injury victims. J Trauma 1971;11:711-4. 4. Kondo Y, Abe T, Kohshi K, Tokuda Y, Cook EF, Kukita I. Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score. Crit Care 2011;15:R191. 5. Sartorius D, Le Manach Y, David JS, Rancurel E, Smail N, Thicoïpé M, et al. Mechanism, glasgow coma scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients. Crit Care Med 2010;38:831-7. 6. Llullaku SS, Hyseni NSh, Bytyçi CI, Rexhepi SK. Evaluation of trauma care using TRISS method: the role of adjusted misclassification rate and adjusted w-statistic. World J Emerg Surg 2009;4:2. 7. Joosse P, Soedarmo S, Luitse JS, Ponsen KJ. Trauma outcome analysis of a Jakarta University Hospital using the TRISS method: validation and limitation in comparison with the major trauma outcome study. Trauma and Injury Severity Score. J Trauma 2001;51:134-40. 8. Champion HR. Trauma scoring. Scand J Surg 2002;91:12-22. 9. Senkowski CK, McKenney MG. Trauma scoring systems: a review. J Am Coll Surg 1999;189:491-503. 10. Hargrove J, Nguyen HB. Bench-to-bedside review: outcome predictions for critically ill patients in the emergency department. Crit Care 2005;9:376-83. 11. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983;249:28-35. 12. Subbe CP, Slater A, Menon D, Gemmell L. Validation of physiological scoring systems in the accident and emergency department. Emerg Med J 2006;23:841-5. 13. Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: which scoring system? Injury 2004;35:34758. 14. Guenther S, Waydhas C, Ose C, Nast-Kolb D; Multiple Trauma Task Force, German Trauma Society. Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service. J Trauma 2003;54:973-8. 15. Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med 1981;9:672-6.

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Ahun et al. The mortality of major trauma patients presenting to the emergency department

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Acil servise başvuran majör travma hastalarının mortalite tahmininde Glasgow koma skalası, yaş ve arteriyel kan basıncı skorunun değerliliği Dr. Erhan Ahun,1 Dr. Özlem Köksal,1 Dr. Deniz Sığırlı,2 Dr. Gökhan Torun,1 Dr. Serdar Suha Dönmez,1 Dr. Erol Armağan1 1 2

Uludağ Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Bursa; Uludağ Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Bursa

AMAÇ: Bu çalışmanın amacı yeni bir travma skorlama sistemi olan GAP skorunun Acil Servis’e (AS) başvuran majör travma hastalarında mortalite tahmin gücünü değerlendirmektir. GEREÇ VE YÖNTEM: Uludağ Üniversitesi Tıp Fakültesi Hastanesi AS’ye başvuran ≥18 yaş majör travmalı 100 hasta çalışmaya alındı. Hasta verileri ileriye yönelik olarak değerlendirilerek hastaların RTS, ISS, TRISS, MGAP ve GAP skorları hesaplandı. BULGULAR: Hastane içi mortaliteyi öngörmede, ISS, TRISS, MGAP ve GAP arasında pozitif yönde anlamlı bir korelasyon saptandı (p<0.0001). Travma skorlama sistemlerinin sırasıyla kısa dönem (24 saat) ve uzun dönem (4 hafta) mortalite tahmin oranları ROC analizinde Eğri Altındaki Alan (EAA)- Area Under Curve (AUC); RTS için 0.727- 0.680, ISS için 0.863-0.816, TRISS için 0.945-0.911 MGAP için 0.970-0.938, GAP için 0.9100.904 olarak bulundu. Hesaplanan travma skorlarının hepsinin mortalite tahmin gücü anlamlı olarak bulundu (p<0.001). GAP’ın hem AS’de, hem de hastane içi mortaliteyi öngörmede istatistiksel olarak anlamlı bir şekilde (p=0.0001) seçici ve duyarlı olduğu belirlendi. TARTIŞMA: Bu sonuçlarla GAP skorunun travma hastalarında, hem sahada ve hem de başvuru anında AS’de kolayca hesaplanabilecek ve hastanın mortalitesini öngörerek AS doktoruna fikir verebilecek bir skorlama sistemi olduğunu düşünmekteyiz. Anahtar sözcükler: Majör travma; mortalite; travma skorlama sistemleri. Ulus Travma Acil Cerrahi Derg 2014;20(4):241-247

doi: 10.5505/tjtes.2014.76399

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ORIGIN A L A R T IC L E

Impact of smoking on trauma patients Shelby Resnick, M.D., Kenji Inaba, M.D., Obi Okoye, M.D., Lauren Nosanov, M.D., Daniel Grabo, M.D., Elizabeth Benjamin, M.D., Jennifer Smith, M.D., Demetrios Demetriades, M.D. LAC+USC Medical Center, Los Angeles, California, United States of America

ABSTRACT BACKGROUND: The harmful effects of smoking have been well-documented in the medical literature for decades. To further the support of smoking cessation, we investigate the effect of smoking on a less studied population, the trauma patient. METHODS: All trauma patients admitted to the surgical intensive care unit at the LAC + University of Southern California medical center between January 2007 and December 2011 were included. Patients were stratified into two groups - current smokers and non-smokers. Demographics, admission vitals, comorbidities, operative interventions, injury severity indices, and acute physiology and chronic health evaluation (APACHE) II scores were documented. Uni- and multi-variate modeling was performed. Outcomes studied were mortality, duration of mechanical ventilation, and length of hospitalization. RESULTS: A total of 1754 patients were available for analysis, 118 (6.7%) patients were current smokers. The mean age was 41.4Âą20.4, 81.0% male and 73.5% suffered blunt trauma. Smokers had a higher incidence of congestive heart failure (4.2% vs. 0.9%, p=0.007) and alcoholism (20.3% vs. 5.9%, p<0.001), but had a significantly lower APACHE II score. After multivariate regression analysis, there was no significant mortality difference. Patients who smoked spent more days mechanically ventilated (beta coefficient: 4.96 [1.37, 8.55, p=0.007]). CONCLUSION: Smoking is associated with worse outcome in the critically ill trauma patient. On an average, smokers spent 5 days longer requiring mechanical ventilation than non-smokers. Key words: Critical care; mechanical ventilation; smoking; trauma.

INTRODUCTION Tobacco use is the number one cause of preventable death in the United States (US).[1] Over 440,000 deaths are attributed to smoking annually. In addition, billions of dollars are spent every year directly on medical expenses to treat smoking related diseases.[2,3] The chronic health effects of smoking are well-documented in the medical literature. In addition to be being linked to long-term diseases including, cancer, chronic bronchitis, and emphysema, studies in the surgical literature show patients Address for correspondence: Shelby Resnick, M.D. 2051 Marengo St. IPT, C5L100 90027 Los Angeles - United States Tel: 9492959279 E-mail: shelby.resnick@med.usc.edu Qucik Response Code

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who smoke have worse outcomes than prior or non-smokers.[4-9] A recent study, using the large National Surgical Quality Improvement Program (NSQIP) database found smokers had a 30% increased risk of developing major perioperative morbidity or mortality.[4] There are multiple mechanisms by which smoking contributes to worse surgical outcomes. Smoking is recognized as a risk factor for poor wound healing, cardiovascular and thromboembolic events, respiratory compromise and need for prolonged mechanical ventilation, after surgery.[5,6] In addition, the host inflammatory response is altered leading to an inability to control bacterial contamination resulting in increased post-operative infections.[7] Given the breadth of literature regarding the pathophysiology of smoking on the respiratory system, the increase in pulmonary complications is not surprising. The basic protective mechanisms of the airway are lost.[8,9] Small airways are narrowed, mucus secretion is increased, and the cilia lining the respiratory tract become dysfunctional reducing the hostâ&#x20AC;&#x2122;s ability to clear inhaled toxins leading to epithelial damage, oxidative injury, and chronic inflammation. Damage to the cilUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Resnick et al. Impact of smoking on trauma patients

ia and alveolar macrophages worsen the respiratory defense contributing to the increased number of smokers with postoperative pneumonias.[6]

All statistical analysis was performed using Statistical Package for Social Sciences (SPSS Windows©), version 17.0 (SPSS Inc., Chicago, IL, USA).

Despite the overwhelming evidence to abstain, 20% of the population smokes.[2,3] When stratified by age and gender the prevalence is highest in males and the 18-24 years old population.[3] Probably not coincidentally, this is the demographic also most commonly associated with traumatic injury.[10] Therefore, we thought it pertinent to investigate the impact of smoking on the acutely injured patient. We hypothesized that patients who smoked at the time of injury will have an increased incidence of complications, specifically respiratory.

RESULTS

MATERIALS AND METHODS Approval for this study was obtained from the University of Southern California Institutional Review Board. This retrospective study was conducted in the verified, level one trauma center, admitting an average of 5000 trauma patients, annually. Each year, our 30 bed surgical intensive care unit (SICU) admits over 1200 patients, including all critically injured patients. All trauma patients admitted to the SICU, between January 2007 and December 2011, were identified. Patients were stratified into two groups – current smokers and nonsmokers. Smoking status was determined from the admitting physician’s history and physical, physician consultation notes and/or nursing documentation in the chart. Patients were excluded from analysis if smoking status was unknown. Demographics, admission vital signs, Glasgow coma scale (GCS), comorbidities, operative interventions, injury severity indices, acute physiology and chronic health evaluation (APACHE) II scores, and complications were abstracted. Outcomes variables collected included mortality, duration of mechanical ventilation, SICU length of stay (LOS) and overall length of hospitalization. Descriptive statistics are reported using means ± standard deviations for continuous variables and percentages for categorical variables. Certain continuous variables were dichotomized using clinically relevant cut-points to include age ≥55 years, admission GCS ≤8, injury severity score (ISS) ≥25, abbreviated injury scale ≥3, and hypotension, defined as a systolic blood pressure ≤90 mmHg. Normality testing for continuous variables was done using the Shapiro–Wilk test, and compared using Student’s t-test or Mann–Whitney U-test as appropriate, while dichotomous variables were compared using Chi-square or Fisher’s exact test. Outcomes were analyzed using multivariate analyses adjusting for variables differing significantly at p<0.05 from the univariate analysis. Results of the multivariate analysis are reported as adjusted odds ratio (OR) and beta coefficients for the dichotomous and continuous outcome variables, respectively. Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

A total of 1754 trauma patients were eligible for analysis. Of these patients, 118 (6.7%) were identified as current smokers. In comparison of the two groups, the current smoker and non-smoker cohorts were equally matched in most categories. The majority, in both groups, was male and sustained blunt trauma. Overall, patients were young, with only a quarter of the patients in each group over 55 years of age. Comparing comorbidities, the current smokers had a higher incidence of congestive heart failure (4.2% vs. 0.9%, p=0.007) and alcoholism (20.3% vs. 5.9%, p<0.001). In regards to injury severity at the time of admission, current smokers had higher GCS (14.4±1.8 vs. 12.7±3.9) and less patients had a head abbreviated injury score (AIS) >3 (22% vs. 35%). Groups were similar in chest, abdominal and extremity AIS and ISS. The current smokers had a significantly lower APACHE II score (12.5±7.2 vs. 16.5±9.6) when compared to the non-smoker group. Difference in heart rate was statistically significant (p=0.015) between the two groups, however, not considered clinically significant (92.5 vs. 98.7 bpm). There was no significant difference between the current smokers and non-smokers in regards to open chest or abdominal explorations. Comparison of the two groups is shown in Table 1.

Outcomes Hospital and ICU LOS was equivalent between the current smokers and non-smokers. On uni- and multi-variate analysis there was no significant difference between the two groups. Mortality rate was significantly higher in the non-smokers (7.6%) than the current smokers (2.5%, p=0.042). However, on multivariate analysis the difference in mortality between the two groups did not reach statistical significance (p=963). Comparison of the total days spent requiring mechanical ventilation differed significantly on multivariate analysis. The current smoker group spent, on average, 5 more days on the ventilator than the non-smokers. Outcome comparisons are shown in Table 2.

DISCUSSION Our study demonstrates that patients who smoke and suffer major trauma have a significantly higher risk of requiring prolonged mechanical ventilation. Despite being less criticallyill, as indicated by the lower APACHE II and head AIS and higher GCS, smoking was associated with worse outcomes. The smokers in our study spent an average of 5 days longer requiring mechanical ventilation than the non-smokers. About 50% of injuries occur in patients under the age of 249

Resnick et al. Impact of smoking on trauma patients

Table 1. Cohort comparison

Current smokers (n=118)

Age 41.2±18.7

Non-smokers (n=1636)

39.9±22.8

0.778

Age ≥55

24.6% (29/118)

25.3% (414/1636)

0.860

Gender (Male)

87.3% (103/118)

80.6% (1318/80.6)

0.088

Comorbidities

Alcoholism

20.3% (24/118)

5.9% (97/1636)

<0.001

Hypertension

22.9% (27/118)

16.0% (261/1636)

0.050

Diabetes

14.4% (17/118)

9.4% (154/1636)

0.077

Congestive heart failure

4.2% (5/118)

0.9% (14/1636)

0.007

Respiratory disease

4.2% (5/118)

2.1% (35/1636)

0.186

End stage renal disease on dialysis

2.5% (3/118)

1.4% (23/1636)

0.253

Obesity

0.8% (1/118)

1.9% (31/1636)

0.720

Blunt trauma

72.9% (86/118)

73.6% (1205/1636)

0.865

Systolic blood pressure

Hypotension

132.6±25.6

131.8±29.3

0.864

5.2% (6/115)

6.7% (107/1609)

0.549

Heart rate

92.5±19.6

98.7±26.0

0.015

Admission Glasgow coma scale

14.4±1.8

12.7±3.9

<0.001

Glasgow coma scale ≤8

2.7% (3/112)

17.1% (274/1599)

<0.001

Head Abbreviated injury score >3

22.0% (26/118)

35.5% (580/1636)

0.003

Chest Abbreviated injury score

39.0% (46/118)

35.1% (574/1636)

0.392

Abdominal Abbreviated injury score

23.7% (28/118)

18.9% (310/1636)

0.204

Extremity Abbreviated injury score

20.3% (24/118)

21.6% (354/1636)

0.740

Injury severity score

15.3±10.8

16.6±10.9

0.102

Injury severity score >25

22.0% (26/118)

22.9% (374/1635)

0.834

APACHE II score

12.5±7.2

16.5±9.6

<0.001

Thoracotomy/sternotomy

1.7% (2/118)

3.7% (61/1636)

0.436

Laparotomy

18.6% (22/118)

21.3% (348/1636)

0.499

APACHE: Acute physiology and chronic health evaluation.

Table 2. Outcomes Mortality HLOS*

Smokers (n=118)

Non-smokers (n=1636)

AOR (95% CI)/beta (95% CI)

2.5% (3/118)

7.6% (125/1636)

1.03 (0.28, 3.81)

0.963

14.4±17.5

14.8±24.9

0.69 (−4.05, 5.43)

0.766

ICU LOS*

9.1±15.1

8.6±11.3

2.10 (−0.02, 4.22)

0.052

Total ventilator*

11.9±21.2

7.9±11.3

4.96 (1.37, 8.55)

0.007

*Measured in days. AOR: Adjusted odds ratio; CI: Confidence interval; HLOS: Hospital length of stay; ICU: Intensive care unit; LOS: Length of stay.

45.[10] Accordingly, the mean age for both our smoker and non-smoker cohort was 40, considerably younger than the average patient age in the rest of the literature on surgery and smoking. One of the largest studies, on the effects of smoking in the surgical patient was based on the Veteran Affairs database, an older male population.[5] In the large NSQIP study by Sharma et al.,[4] the median age was 60. Our study 250

looked not at the elderly, comorbid smoking patient, but at the critically injured smoker. Despite being young and less critically ill the smokers still had worse outcomes than nonsmokers. The study findings mimic those published in the elective surgical literature. Ngaage et al.,[8] analyzed 2163 elective cardiac Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Resnick et al. Impact of smoking on trauma patients

surgery patients. 10% of the patients, despite preoperative counseling, were active smokers at the time of surgery. These patients required a longer duration of mechanical ventilation and were twice as likely to experience post-operative pulmonary complications. Regardless of the surgical specialty the risk of smoking preoperatively has been demonstrated. Hawn et al.,[5] looked at over 100,000 smokers who underwent elective surgery across multiple surgical disciplines. Smokers were across the board more likely to suffer surgical complications, including wound infections, deep vein thrombosis, myocardial infarctions, and mortality. Respiratory complications, including pneumonias, prolonged mechanical ventilation and reintubation, were also markedly increased in patients with a smoking history. Even after accounting for complexity of procedure, the increased complication rates applied across all surgical procedures. The effect of smoking on patients undergoing elective surgery is well-documented; however, the impact on outcomes after acute injury has been minimally investigated. To the best of our knowledge, only two other studies have looked specifically at the trauma population when assessing the risks of smoking. Calfee et al.[11] followed severe blunt trauma patients for the development of acute lung injury (ALI). To accurately identify, the smoking cohort, plasma cotinine levels were measured upon patient’s arrival to the emergency department. Cotinine, a metabolite of nicotine can quantify cigarette smoke exposure. Patients with the highest levels of cotinine, the identified active smokers, were over 3 times more likely to develop ALI than patients with the lowest levels, the identified non-smokers. Interestingly, with this method, patients who were exposed to heavy secondhand smoke were also able to be studied. Patients exposed to moderate to high levels of secondhand smoke had a nearly equivalent risk for developing ALI as the active smokers (OR, 3.03; 95% confidence interval, 1.15-8.04). The findings reported by Nguyen-Ferro et al.[12] failed to show any statistically significant differences between a smoker and non-smoker outcomes in the 327 severely injured patients they studied. However, both the need for intubation and the occurrence of respiratory failure were increased in the identified smoker cohort. This study faced the same limitations as ours, being retrospective and having unreliable smoking documentation. In addition, their sample size was smaller, which may account for the lack of statistical significance. As previously mentioned, our study was limited by the inherent biases of a retrospective study. The smoking prevalence of our trauma population is almost certainly underestimated. One-fifth of the US population currently smoke, and this percentage is higher in the trauma patient population.[2,3] The smoker cohort in our study accounted for only 6.7% of our overall patient population. It is difficult to retrospectively obUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

tain accurate documentation of smoking status, especially in the critically ill, intubated and sedated patients. Patients who were not identified at the time of admission as current smokers were not included in this study. Smokers are more likely to be classified as non-smokers than the other way around.[11] Calfee et al., found 41% of patients demonstrated to be active smokers based on cotinine levels were not documented as such in the chart. These inaccuracies likely only underestimate the harmful effect of smoking on the trauma patient. Future studies should be focused on accurate documentation of patient’s smoking histories, including the amount and duration. Inclusion of patients with second hand smoke exposure and previous smokers would also be of interest to analyze and compare to current smokers.

Conclusion Smoking is associated with a worse pulmonary outcome in the critically injured patient. Smokers were mechanically ventilated for longer periods of time, on average, 5 days more. The impact of smoking in the trauma patient warrants future, prospective study. Programs promoting smoking cessation, especially in the younger, trauma prone population, are strongly encouraged. Conflict of interest: None declared.

REFERENCES 1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-57. 2. Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years--United States, 20052010. MMWR Morb Mortal Wkly Rep 2011;60:1207-12. 3. King BA, Dube SR, Tynan MA. Current tobacco use among adults in the United States: findings from the National Adult Tobacco Survey. Am J Public Health 2012;102:e93-e100. 4. Sharma A, Deeb AP, Iannuzzi JC, Rickles AS, Monson JR, Fleming FJ. Tobacco smoking and postoperative outcomes after colorectal surgery. Ann Surg 2013;258:296-300. 5. Hawn MT, Houston TK, Campagna EJ, Graham LA, Singh J, Bishop M, et al. The attributable risk of smoking on surgical complications. Ann Surg 2011;254:914-20. 6. Khullar D, Maa J. The impact of smoking on surgical outcomes. J Am Coll Surg 2012;215(3):418-26. 7. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012;255:1069-79. 8. Ngaage DL, Martins E, Orkell E, Griffin S, Cale AR, Cowen ME, et al. The impact of the duration of mechanical ventilation on the respiratory outcome in smokers undergoing cardiac surgery. Cardiovasc Surg 2002;10:345-50. 9. Centers for Disease Control and Prevention (US); National Center for Chronic Disease Prevention and Health Promotion (US); Office on Smoking and Health (US). How Tobacco Smoke Causes Disease: The

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Resnick et al. Impact of smoking on trauma patients Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2010. 10. Brasel KJ, Esposito TJ. Epidemiology. Chapter 2. In: Mattox KL, Moore EE, Feliciano DV, editors. Trauma. 7th ed. New York: McGraw-Hill; 2013.

11. Calfee CS, Matthay MA, Eisner MD, Benowitz N, Call M, Pittet JF, et al. Active and passive cigarette smoking and acute lung injury after severe blunt trauma. Am J Respir Crit Care Med 2011;183:1660-5. 12. Ferro TN, Goslar PW, Romanovsky AA, Petersen SR. Smoking in trauma patients: the effects on the incidence of sepsis, respiratory failure, organ failure, and mortality. J Trauma 2010;69:308-12.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Travma hastalarında sigaranın etkisi Dr. Shelby Resnick, Dr. Kenji Inaba, Dr. Obi Okoye, Dr. Lauren Nosanov, Dr. Daniel Grabo, Dr. Elizabeth Benjamin, Dr. Jennifer Smith, Dr. Demetrios Demetriades LAC+USC Tıp Merkezi, Los Angeles, California, Amerika Birleşik Devletleri

AMAÇ: Onyıllardan beri tıp literatüründe sigara içmenin zararlı etkileri iyice belgelenmiştir. Sigara bırakmaya ilave destek sağlamak için sigara içiminin daha az incelenmiş bir popülasyonda, travma hastalarındaki etkisini inceliyoruz. GEREÇ VE YÖNTEM: Ocak 2007 ile Aralık 2011 arasında LAC + Güney Kaliforniya Üniversitesi (University of Southern California) tıp merkezi cerrahi yoğun bakım ünitesine kabul edilen travma hastalarının hepsi çalışmaya dahil edildi. Hastalar halihazırda sigara içenlerle içmeyenler olarak iki gruba ayrıldı. Demografik özellikler, kabuldeki yaşamsal bulgular, komorbiditeler, cerrahi girişimler, travma şiddet derecesi indeksleri, akut fizyoloji ve kronik sağlık değerlendirmesi (APACHE) II skorları kaydedildi. Tek ve çok değişkenli analizler uygulandı. İncelenen son noktalar mortalite, mekanik ventilasyon tedavisinde kalma ve hastanede yatış süresiydi. BULGULAR: Analize 118’i (%6.7) sigara kullananlar olmak üzere toplam 1754 hasta alındı. Yaş ortalaması 41.4±20.4, yıl olup, hastaların %81.0’i erkek idi. Hastaların %73.5’i kafa travması geçirmişti. Sigara içenlerde konjestif kalp yetersizliği (%4.2’ye karşın %0.9; p=0.007) ve alkolizm (%20.3’e karşın %5.9, p<0.001) insidansı daha yüksek olmasına karşın APACHE II skoru anlamlı derecede daha düşüktü. Çok değişkenli regresyon analizinde mortalitede anlamlı bir farklılık saptanmadı. Sigara içicisi hastalar mekanik ventilasyon tedavisinde daha uzun süre kaldı (beta katsayısı: 4.96 [1.37; 8.55, p=0.007]). TARTIŞMA: Sigara kullanımı kritik travma hastasında daha kötü sonuçlarla ilişkilidir. Sigara kullanmayanlara gtöre sigara içiciler mekanik ventilasyonda beş gün daha uzun süre kalmıştır. Anahtar sözcükler: Kritik hasta bakımı; mekanik ventilasyon; sigara kullanımı; travma. Ulus Travma Acil Cerrahi Derg 2014;20(4):248-252

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doi: 10.5505/tjtes.2014.21737

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ORIGIN A L A R T IC L E

Etiology and prognosis of penetrating eye injuries in geriatric patients in the Southeastern region of Anatolia Turkey Harun Yüksel, M.D., Fatih Mehmet Türkcü, M.D., Yasin Çınar, M.D., Abdullah Kürşat Cingü, M.D., Alparslan Şahin, M.D., Muhammed Şahin, M.D., Zeynep Özkurt, M.D., Mehmet Murat, M.D., İhsan Çaça, M.D. Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakir

ABSTRACT BACKGROUND: The purpose of this study was to evaluate the etiologic and prognostic factors of open eye injuries in geriatric patients in the Southeastern region of Anatolia. METHODS: Forty-five geriatric patients who underwent surgery for an open eye injury in our clinic between the years of 2008 and 2012 were evaluated retrospectively. Age, gender, cause and the mechanism of the trauma, visual acuity (VA), and the time between the trauma and the surgery were obtained from files and evaluated. RESULTS: The mean age of the patients was 70.4±8.2 (65-90) years. Thirty-four of the cases were male and 11 were female. The most frequent mechanism of trauma was a wood strike, while the second most common one was injury with a knife. Corneoscleral penetration was the most frequently observed trauma. The mean VA of the patients was 2.26±0.65 at admission, and was 1.53±0.99 logarithm of the minimum angle of resolution at the final evaluation. The most frequent complications of trauma were iris prolapse and hyphema. There was a significant correlation between the first and final VA. CONCLUSION: Penetrating ocular injuries are seen less frequently among geriatric patients, and their prognosis may be worse due to less-efficient wound site healing and differences in scleral rigidity. The most important factor affecting the final VA measurement was the VA of the patient at admission. Key words: Eye; geriatric; injury.

INTRODUCTION Ocular traumas, especially penetrating injuries, are among the most common causes of preventable vision loss.[1] Ocular traumas constitute 7% of all bodily injuries and 10-15% of all eye diseases.[2,3] Ocular traumas are a public health problem, which brings an important functional, medical, and socioeconomic burden; they are important because of their preventable character.[4] Ocular penetrating traumas are most frePresented at the 47th National Congress of Ophthalmology Society (November 6-10, 2013, Antalya Turkey).

Address for correspondence: Fatih Mehmet Türkcü, M.D. Dicle Üniversitesi Tıp Fakültesi, Göz Anabilim Dalı, Diyarbakır, Turkey Tel: +90 412 - 248 80 01 E-mail: turkcufm@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

quently seen in children and adolescent patients.[5] Therefore, there is a limited number of studies regarding ocular traumas in geriatric patients.[6,7] Factors affecting the prognosis of ocular penetrating injuries have been previously reported. Factors such as advanced age, poor initial visual acuity (VA), type and extent of the injury, presence of vitreous hemorrhage and/or retinal detachment were reported to negatively affect the prognosis.[8-10] However, there is limited information about factors affecting prognosis in geriatric cases.[6,7] In this study, we aimed to investigate the causes of ocular penetrating injuries as well as features, and factors affecting prognosis in geriatric cases.

MATERIALS AND METHODS Forty-five geriatric patients (≥65 years of age) who underwent surgery for an open eye injury at Dicle University’s Faculty of Medicine, Departments of Ophthalmology, between the years of 2008 and 2012 were evaluated retrospectively. 253

Yüksel et al. Etiology and prognosis of penetrating eye injuries in geriatric patients in the Southeastern region of Anatolia Turkey

Table 1. Cause of ocular trauma in geriatric patients

Patients older than 65 years of age that had not undergone any previous eye surgery except for cataract surgery with a follow-up period of with for at least 6 months in our clinic were included in the study.

n %

Wood

16 35.6

Knife

8 17.8

Statistical Analysis

Fall

7 15.6

Horn strike

Stone

3 6.7

Metallic object

Accident

2 4.4

Data were presented as arithmetical mean ± standard deviation. Statistical analyses of quantitative data, including descriptive statistics and parametric/non-parametric comparisons, were performed for all variables. Frequency analyses were performed with a chi-square test.

Needle

2 4.4

Total

45 100

8.9 6.7

Approval for this study was received from the Local Ethical Committee. Age, gender, best corrected visual acuity (BCVA) at first admission and follow-up examinations, the cause of injury, laterality, the location of the perforation, the time between the trauma and admission to our clinic, previous surgical operations, anterior and posterior segment findings were noted from patient records. Cases that had a ≥6-month follow-up period were included in the study. BCVA at the last examination and other surgeries that took place during that period (vitrectomy, lensectomy with phaco-intraocular lens and evisceration) were recorded.

Multiple logistic analyses were performed in order to determine the combinations of clinical factors related to ocular trauma that predict the final BCVA. The multivariate model included factors found by univariate analyses to be significant predictors of final visual outcome (p≤0.05, univariate analysis). Statistical analyses were performed with the Statistical Package for the Social Sciences version 15.0 (SPSS Inc., Chicago, IL, USA) software. p<0.05 was considered to be statistically significant.

RESULTS Thirty-four (75.3%) of the included cases were male and 11 (24.7%) were female. Twenty-three cases (51.1%) injured the right eye and 22 cases (48.9%) injured the left eye. The mean age of the patients was 70.4±8.2 (65-90) years. The average follow-up period was 7.9±2.9 (6-17) months.

Injuries were classified as corneal, scleral, or corneoscleral according to the location of the perforation. Cases were divided into five groups according to the time between the trauma and admission to the clinic (0-12 hours, 12-24 hours, 24-48 hours, 48-72 hours, and more than 72 hours). We used the ocular trauma score (OTS) method for each patient, which is based on the birmingham eye trauma terminology system, during the classification of the mechanical trauma.[11]

Traumas were caused by blunt objects in 66.7% of the patients. The most common trauma was caused by a wood strike, and the second most common one was caused by a knife touch (Table 1).

The BCVA of the cases were evaluated with the Snellen Chart. BCVA were converted to the logarithm of the minimum angle of resolution (logMAR) for calculations.

The mean BCVA was 2.19±0.68 logMAR at admission and was 1.53±0.99 logMAR at the 6th month of the follow-up (Table 2). The BCVA at admission was 1.30 logMAR in 11 cases; at hand motion level in 21 cases, and at light perception level in 13 cases. The BCVA at the 6th month follow-up was 1.30 logMAR in 29 cases, at hand motion level in six cases, and at light perception level in 10 cases.

All cases underwent primary suturation under general anesthesia. A 10/0 nylon suture was used for suturing the cornea and a 7/0 Vicryl (polyglactin 910) suture was used for the sclera.

The majority of the penetrating injuries was corneoscleral n=22 (48.9%), followed by scleral n=13 (28.9%) and corneal n=10 (22.2%) injuries.

Table 2. Initial uncorrected and final best corrected visual acuity of patients in the study

Corneal injuries (n=10)

Corneoscleral injuries (n=22)

Scleral injuries (n=13)

Initial BCVA (logMAR)

2.24±0.67

2.26±0.72

2.03±0.64

0.690

Final BCVA (logMAR)

1.57±0.99

1.80±1.03

1.06±0.81

0.074

logMAR: Logarithm of the minimum angle of resolution; BCVA: Best corrected visual acuity.

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OTS scores were one in 24 (53.3%) patients, two in six (13.3%) patients, three in 12 (26.7%) patients and four in three (6.7%) patients.

were cataracts and retinal detachment. The most frequent surgery undergone during the follow-up period was cataract surgery (Table 5).

The majority (44.4%) of the patients applied to our clinic within 24-48 hours of the trauma. The earliest admission occurred within 1 hour after the trauma, and the latest admission was 72 hours after the trauma (Table 3).

Twenty-six cases (57.8%) had already undergone cataract surgery at the time of admission. There was no statistically significant difference in location of the penetrating injury between the phakic and pseudophakic eyes (p=0.510).

Associated findings with ocular penetrations are presented in Table 4. The most common preoperative examination findings were iris prolapse and hyphema.

Correlation analysis revealed a negative correlation between age and first BCVA (p=0.048 r=0.296) and between first and final BCVA (p<0.001, r=0.766). Linear regression analysis revealed that the initial BCVA was the only variable to significantly affect final BCVA (p=0.008, R2=0.592).

The most common complications during the follow-up visit Table 3. The time between the trauma and admission to the clinic Hours

n %

0-12

8 17.8

12-24

11 24.4

24-48

20 44.4

48-72

1 2.2

After 72

Total

45 100

11.1

Table 4. Anterior and posterior segment findings at the time of admission

n %

Iris prolapse

Hyphema

10 22.2

42.2

Vitreous at the wound

Endophthalmitis

3 6.7

Cataract

2 4.4

Foreign body

2.2

Traumatic evisceration

2.2

Retinal detachment

2.2

Lens drop

2.2

Anterior chamber foreign body

2.2

6.7

Table 5. Associated surgeries during the follow-up period

n %

Cataract surgery (Phaco-IOL)

31.1

Pars plana vitrectomy

15.6

Evisceration

3 6.7

IOL: Intraocular lens.

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A chi-square test revealed that presence of hyphema, iris prolapse, or cataracts were not different between the patients who had 0.1 or higher BCVA and others at the time of admission.

DISCUSSION Ocular trauma is one of the leading causes of unilateral preventable visual impairment and loss in the world. Especially in the pediatric age group the most important cause of unilateral visual impairment is ocular trauma.[5,12] Recovery from penetrating eye injuries in geriatric cases is different from that of other age groups.[6,7] In this study, we evaluated the factors affecting prognosis of penetrating eye injuries in geriatric cases. It has been reported that males are more frequently affected by ocular traumas (72-95% frequency).[1,5,8,13] However, one study reported that the male:female ratio for geriatric cases is 1:1, while another study reported that female cases were more frequent.[6,7] In our study, we found that the male exposure rate was 75.3%, which is compatible with data from other age groups. In a study of geriatric cases by Tök et al.,[6] the mean age of the patients was 73.06±5.99 years and in a study by Andreoli et al.,[7] it was 79.8 years. In our study, the mean age was 70.4±8.2 (65-90) years. Several studies have reported that the right eye is most often affected, but some other studies have reported that trauma occurs most often in the left eye. [1,5,14,15] In this study, there was no significant difference in the exposure rate of trauma between the right (51.1%) and left (48.9%) eyes. Animal breeding and agriculture are among the most important sources of income in the Southeastern region of Anatolia. Because of this, most of the documented traumas are due to wood and horn strike. In our study, ruptured, open eye injuries were seen most commonly seen, consistent with previous reports.[6,7] Eye traumas due to falls were reported at a rate of 65% by Andreoli et al.,[1] and 15.6% by Tök et al.,[2] but in our study, the rate was just 13.4%. 255

Yüksel et al. Etiology and prognosis of penetrating eye injuries in geriatric patients in the Southeastern region of Anatolia Turkey

Corneal injuries are the most common eye injury in the nongeriatric population, while corneoscleral injuries are the most common in the geriatric population. Reasons for this include increased scleral rigidity and increased blunt trauma rates in older persons.[6,7] In our study, we observed scleral or corneoscleral injury in 77.8% of cases. A great majority of them were ruptures caused by blunt traumas. In those cases, BCVA was found to be below hand motion in 15 cases (93.8%) in patients with rupture and in one case (6.2%) with penetrating trauma. It has been reported that visual prognosis is worse for geriatric cases than those in the younger population.[6,7] Several factors affect the visual prognosis for all age groups. It has been accepted that the most important factors are age and VA at admission.[8,9,14,15] In our study, we observed that BCVA at admission was at the level of counting fingers or less in 75.6% of cases. This ratio was reduced to 33.3% at the 6 months postoperatively. The worst prognosis was observed for those with corneoscleral injuries. Among all factors, only age and BCVA at admission were correlated with final BCVA. Multivariate analysis showed that the only factor that affects final BCVA is BCVA at admission. In contrast to our results, Tök et al.,[6] showed that there was a correlation between final BCVA and age, but did not show a correlation between final BCVA and BCVA at admission. In this study, OTS in 53% of the patients was one and that value was consistent with BCVA at postoperative month 6. In previous studies, the endophthalmitis rate after penetrating traumas was reported to be 0.9-12% for all age groups. [16-18] Endophthalmitis has not been previously reported in geriatric cases. Endophthalmitis occurred in three cases in our study, all of which were injured by organic substances. Previous studies have reported that the average time between the trauma and surgery was within the first 24 hours, but in our study, this time was within the first 48 hours. We hypothesize that this increased time between the trauma and the surgery causes an increased risk for endophthalmitis. Previous studies have shown that each day between the trauma and the surgery decreases BCVA 1.16-fold.[9] Traumas occurred at home in 76% of the cases in a study by Andreoli et al.,[7] but in our study, traumas occurred mostly outdoors, and especially in the countryside. This may be another cause for an increased risk of endophthalmitis. The intraocular foreign body (FB) rate in geriatric cases has been reported as 1%.[7] In our study, we observed FB in the vitreous cavity in one case and in the anterior chamber in another case, and an intraocular lens drop in one case. In total, the rate in our study was 6.7% (three cases) which is significantly higher than those in other studies. There was traumatic evisceration in one case at admission. That patient underwent primary suturation; however, phthi256

sis occurred during the follow-up, so we performed an evisceration. There were also two other patients that underwent evisceration. In this study by Tök et al.,[6] there were three eviscerations out of 30 cases. There is a lower evisceration rate for geriatric cases, which can be explained by their lowered esthetic concerns. The most common surgical procedures performed during the follow-up were cataract extraction and vitrectomy. The increased rate of cataract surgery is most likely due to old age and the trauma. Vitrectomy was performed in seven cases during the follow-up because of retinal detachment. To the best of our knowledge, there have been no previous reports regarding surgeries during follow-up in geriatric cases. However, there were reports on eviscerations.[6,7] In these cases, early surgical procedures are important for visual prognosis and rehabilitation. We did not observe any sympathetic ophthalmia. The literature reports that the incidence of sympathetic ophthalmia is 1-2%.[8,10,19] We believe that we did not see any sympathetic ophthalmia in our cases since they underwent routine steroid therapy after surgery or follow-up period was relatively short. Our results indicate that ocular penetrating injuries have a relatively bad prognosis in geriatric cases. We believe that any differences between our study and previous studies can be explained by regional differences. We detected that the most important factors affecting visual prognosis are age and VA at admission.

Acknowledgement We are grateful to Dicle University DUBAP for their sponsorship for English editing of this manuscript. Conflict of interest: None declared.

REFERENCES 1. Liggett PE, Pince KJ, Barlow W, Ragen M, Ryan SJ. Ocular trauma in an urban population. Review of 1132 cases. Ophthalmology 1990;97:581-4. 2. Maltzman BA, Pruzon H, Mund ML. A survey of ocular trauma. Surv Ophthalmol 1976;21:285-90. 3. Hassett PD, Kelleher CC. The epidemiology of occupational penetrating eye injuries in Ireland. Occup Med (Lond) 1994;44:209-11. 4. McGwin G Jr, Xie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol 2005;123:970-6. 5. Keklikci U, Celik Y, Cakmak SS, Sakalar YB, Unlu MK. Evaluation of perforating eye injuries by using cluster analysis. Ann Ophthalmol (Skokie) 2008;40:87-93. 6. Tök L, Yalçın Tök Ö, Özkaya D, Eraslan E, Sönmez Y, Örnek F, et al. Characteristics of open globe injuries in geriatric patients. Ulus Travma Acil Cerrahi Derg 2011;17:413-8. 7. Andreoli MT, Andreoli CM. Geriatric traumatic open globe injuries. Ophthalmology 2011;118:156-9.

Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Yüksel et al. Etiology and prognosis of penetrating eye injuries in geriatric patients in the Southeastern region of Anatolia Turkey 8. Rahman I, Maino A, Devadason D, Leatherbarrow B. Open globe injuries: factors predictive of poor outcome. Eye (Lond) 2006;20:1336-41. 9. Cruvinel Isaac DL, Ghanem VC, Nascimento MA, Torigoe M, KaraJosé N. Prognostic factors in open globe injuries. Ophthalmologica 2003;217:431-5. 10. Rofail M, Lee GA, O’Rourke P. Prognostic indicators for open globe injury. Clin Experiment Ophthalmol 2006;34:783-6. 11. Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol 2004;27:206-10. 12. Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol 2007;18:366-72. 13. Türkcü FM, Yüksel H, Sahin A, Cingü K, Arı S, Cınar Y, et al. Demographic and etiologic characteristics of children with traumatic serious hyphema. Ulus Travma Acil Cerrahi Derg 2013;19:357-62. 14. Altıntaş L, Altıntaş O, Yüksel N, Pirhan D, Ozkan B, Cağlar Y. Pattern of

open eye injuries in northwest Turkey: a retrospective study. Ulus Travma Acil Cerrahi Derg 2011;17:334-9. 15. Soylu M, Sizmaz S, Cayli S. Eye injury (ocular trauma) in southern Turkey: epidemiology, ocular survival, and visual outcome. Int Ophthalmol 2010;30:143-8. 16. Thompson WS, Rubsamen PE, Flynn HW Jr, Schiffman J, Cousins SW. Endophthalmitis after penetrating trauma. Risk factors and visual acuity outcomes. Ophthalmology 1995;102:1696-701. 17. Reynolds DS, Flynn HW Jr. Endophthalmitis after penetrating ocular trauma. Curr Opin Ophthalmol 1997;8:32-8. 18. Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009;147:601-608.e2. 19. Casson RJ, Walker JC, Newland HS. Four-year review of open eye injuries at the Royal Adelaide Hospital. Clin Experiment Ophthalmol 2002;30:15-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Güneydoğu Anadolu Bölgesi’ndeki geriatrik hastalarda delici göz yaralanmalarında etiyoloji ve prognoz Dr. Harun Yüksel, Dr. Fatih Mehmet Türkcü, Dr. Yasin Çınar, Dr. Abdullah Kürşat Cingü, Dr. Alparslan Şahin, Dr. Muhammed Şahin, Dr. Zeynep Özkurt, Dr. Mehmet Murat, Dr. İhsan Çaça Dicle Üniversitesi Tıp Fakültesi, Göz Anabilim Dalı, Diyarbakır

AMAÇ: Güneydoğu Anadolu Bölgesi’nde yaşayan geriatrik hastalarda açık göz yaralanmasının etiyolojik faktörleri ve prognozu etkileyen faktörleri irdelemek. GEREÇ VE YÖNTEM: 2008-2012 yılları arasında kliniğimizde açık göz yaralanması nedeni ile ameliyat edilen ve takibi yapılan 65 yaş ve üstü 45 olgu geriye dönük olarak değerlendirildi. Dosya bilgilerinden olguların yaşı, cinsiyeti, travmanın oluş nedeni ve şekli, görme derecesi, travmanın oluş zamanı ile cerrahi arasında geçen süre değerlendirildi. BULGULAR: Hastaların ortalama yaşı 70.4±8.2 (65-90) yıl idi. Olguların %75.6’sı (n=34) erkek ve %24.4’ü (n=11) kadın idi. Travmanın oluş şekli en sık olarak odun çarpması ve ikinci sıklıkta bıçak değmesi olarak tespit edildi. Korneaskleral penetrasyon en sık olarak izlendi. Görme keskinlikleri müracaat anında 2.26±0.65 logMAR ölçüldü. Travmaya en sık eşlik eden komplikasyon iris prolapsusu ve hifema olarak izlendi. İlk görme keskinliği ile nihai görme keskinliği arasında korelasyon izlendi. TARTIŞMA: Geriatrik olgularda oküler penetran yaralanmalar daha az görülmekle beraber yara yeri iyileşmesi zorluğu ve değişen skleral rijidite nedeniyle daha kötü prognozlu olabileceği düşünüldü. Nihai görme keskinliğini etkileyen en önemli faktörün hastanın müracaat anındaki görme keskinliği olduğu görüldü. Anahtar sözcükler: Geriatri; göz; yaralanma. Ulus Travma Acil Cerrahi Derg 2014;20(4):253-257

doi: 10.5505/tjtes.2014.71597

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ORIGIN A L A R T IC L E

Comparison of trauma scores for predicting mortality and morbidity on trauma patients Reyhan Orhon, M.D.,1 Şevki Hakan Eren, M.D.,2 Şule Karadayı, M.D.,2 İlhan Korkmaz, M.D.,2 Abuzer Coşkun, M.D.,2 Mehmet Eren, M.D.,3 Nurkay Katrancıoğlu, M.D.4 1

Department of Emergency Medicine, Gaziantep State Hospital; Gaziantep;

Department of Emergency Medicine, Cumhuriyet University Hospital, Sivas;

Department of Orthopaedics and Traumatology, Ankara Yenimahalle State Hospital, Ankara;

Department of Cardiovascular Surgery Service, Cumhuriyet University Hospital, Sivas

ABSTRACT BACKGROUND: In this study, we compared the anatomical, and physiological scoring systems trauma revised injury severity score (TRISS), revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS) to each other, to find out the most accurate and reliable trauma score for the risk classification of morbidity and mortality among the trauma patients. METHODS: This is a cross-sectional study, which included 633 patients who admitted to our University Hospital Emergency Department during an 8-month period due to trauma. All blunt and penetrating traumas (traffic accident, assault, etc.) patients above 16 years were included. RESULTS: Arrival time trauma scores (ISS, NISS, RTS, and TRISS) of the patients was calculated. Mean trauma score for the mortality prediction was calculated, and the p value was equal for all (p=0.001). Trauma scores were also analyzed for the hospitalization time in intensive care unit (ICU). While NISS, RTS, and TRISS values were significant (p=0.048, p=0.048, and p=0.017, respectively), ISS value was not significant (p=0.257) for predicting the ICU hospitalization time. Only TRISS was a good predictor for the mechanically ventilation time in ICU patients (p=0.01). CONCLUSION: In conclusion, we determined that the anatomical trauma scores (NISS, ISS) predicted the hospitalization and ICU necessities better, whereas TRISS, an anatomo-physiological trauma score, defined the ICU hospitalization and mechanically ventilation time better. Key words: Morbidity; mortality; trauma; trauma score.

INTRODUCTION Trauma is a heterogeneous disease that affects all age groups with violence more or less. It takes the first place between 1 and 35 age group patients. In 1989, 160,000 people died as a result of trauma in the United States and this number is approximately four times that of those who died from acquired immunodeficiency syndrome in the same year.[1] According Address for correspondence: Şevki Hakan Eren, M.D. Sivas Cumhuriyet Üniversitesi Tıp Fakültesi, 58140 Sivas, Turkey Tel: +90 346 - 258 13 40 E-mail: shakaneren@hotmail.com Qucik Response Code

258

to the Turkey Statistics Institute data 3% of all deaths in our country were due to trauma, and the most common cause of trauma deaths were motor vehicle accidents, 1516 deaths. Twenty-six percent of these deaths were between 20 and 35 ages and 74% were male.[2] Scoring systems are cornerstones of the trauma epidemiology. Graded according to the severity of injury is necessary for the management of trauma and as well as a basic requirement for clinical trials.[3] Trauma revised injury severity score (TRISS) and injury severity score (ISS), are widely used in the estimation of mortality due to injury.[4,5] In many countries, some trauma scores were developed, and continue to be developed, for the peoples exposed to assess the severity of trauma and the resulting damage. Measurable and comparable objective criteria are required for determining the severity of trauma. For this purpose, many anatomical and physiological scoring systems are created.[6-8] Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Orhon et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients

These scoring systems can provide some benefits: (1) objectively determine the level of the injuries, which enables the care units to classify the patient’s centers according to the specified special care they need. (2) The physiological data that are associated with mortality in the early period after an injury can be determined to follow-up the at-risk patients. (3) The scores can be helpful by transporting the patients to the appropriate hospitals. (4) Patients who may benefit the most from treatment may be primarily determined. (5) They can enable to determine the kind of health institutions, which are necessary in this region. (6) Epidemiological databases about the injuries and its severities can be created. (7) According the results obtained in the treatment of trauma patients, the effectiveness of health institutions can be compared.[6,9,10] Thus, can increase the management quality of trauma cases. The scoring systems which are compared are as follows:

and mortality rates. Trauma scores were also calculated for those who were treated as outpatients. On the basis of these results, we determined to find out the trauma scoring system, which can predict best the mortality rate, hospitalization indications, hospitalization duration, ICU and mechanical ventilation requirements, length of stay in intensive care and mechanical ventilation.

A. Anatomical scoring systems • Abbreviated injury scale (AIS) • ISS • New injury severity score (NISS) B. Physiological scoring systems • Glasgow coma scale (GCS) • Revised trauma score (RTS) C. Combined scoring system • TRISS

RESULTS

The patients under 16 years, burns, pathologic fractures and the ones who died in the emergency department were excluded from the study. Statistical Package for Social Sciences 14.0 was used for analyses. Chi-square, the significance test for the difference between two means, Man-Whitney U-test and correlation analysis were performed. Our data are shown in tables as mean ± standard deviation and p<0.05 was accepted as significant.

The mean age values of 633 individuals were 39.65±17.07 (16-87) years. 482 (%76.1) patients were male and 151 (23.9%) female, 531 (83.8%) cases had blunt trauma, whereas 102 (16.1%) suffered from penetrating trauma. Eight patients (1.3%) could not survive. The treatment of the 378 (%59.7) patients was made in hospital, whereas 255 (%40.3) patients were discharged after their first treatment in the emergency department. Thirty-eight inpatients were directed to ICU and 20 patients needed mechanical ventilation.

MATERIALS AND METHODS This is a cross-sectional study, included 633 trauma patients who admitted Hospital Emergency Department between November 2009 and July 2010. The ethical approval number was taken from the Local Ethics Committee.

The trauma scores for all individuals are shown in Table 1. The minimum score for all trauma scores was 0.0 point; the maximum scores were 41.0, 48.0, 7.84, and 99.7 points for ISS, NISS, RTS, and TRISS, respectively.

This is a descriptive study with cross-sectional properties. The arrival time trauma scores (ISS, NISS, RTS, and TRISS) were calculated both blunt and penetrating trauma patients who were over 16-year-old. The trauma scores were calculated according to their physiological and anatomical criteria such as age, injury mechanism, GCS, pulse rate, blood pressure, respiratory rate, type and degree of the internal and external organ lesions.

All mean trauma scores of the death patients were significantly higher than survived patients (p=0.001). Accordingly, all trauma scores were equal for predicting the mortality (Table 2).

The inpatients were followed-up for their hospitalization, intensive care unit (ICU), and mechanical ventilation time

The trauma scores of the discharged and hospitalized patients were calculated and compared. While trauma scores of ISS and NISS were higher among hospitalized patients, RTS and TRISS were higher in patients who were discharged from the emergency department. The difference was statistically significant for all trauma scores (p<0.05, Table 3). However,

Table 1. Trauma scores for all patients Injury severity score

Minimum

Maximum

Mean±SD

633

0.00

41.00

6.02±7.11

New injury severity score

633

0.00

48.00

7.18±8.51

Revised trauma score

633

0.00

7.84

7.73±0.54

Trauma revised injury severity score

633

0.00

99.7

98.02±7.42

SD: Standard deviation.

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Orhon et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients

Table 2. Mean trauma score for the patients who died and survived Trauma scores

Living patients

Mean±SD Mean±SD Injury severity score

24.37±12.85

625

5.78±6.71

=0.001

New injury severity score

27.62±12.85

625

6.92±8.13

=0.001

Trauma revised injury severity score

72.80±19.35

625

98.34±6.58

=0.001

Revised trauma score

5.62±1.31

625

7.75±0.46

=0.001

SD: Standard deviation.

according to the t-test statistic values the prediction score rate for hospitalization is defined better by anatomical scoring systems (NISS, ISS) then physiological or combined scoring systems (TRISS, RTS). The hospitalization time has a positive correlation with ISS (r=0.36) and NISS (r=0.42). Whereas RTS and TRISS have a negative correlation (r=−0.2 and r=−0.14) with the hospitalization time. In spite of the fact that the p values were statistically significant, the correlation coefficient was weak in all trauma scores for hospitalization time (Table 4). From the 378 hospitalized patients, 38 hospitalized in the

ICU. The service and ICU mean trauma scores were compared. The mean values were statistically different (p<0.05, Table 5). ICU patients had a higher ISS and NISS score, and a lower RTS and TRISS score for patients who were hospitalized in trauma services (Table 5). According to the correlation analyses the hospitalization time in the ICU was statistically significant for NISS, RTS, and TRISS scores (Table 6), whereas the correlation coefficient was weak for all this trauma scores. From 38 patients who were admitted in ICU, 20 patients were mechanically ventilated. The trauma scores were significantly different between the mechanically ventilated and nonmechanically groups (p<0.05, Table 7). According to the p

Table 3. Trauma scores of in- and out-patients Trauma scores

Inpatient trauma score (n=378)

Outpatient trauma score (n=255)

Mean±SD Mean±SD

Injury severity score

8.85±7.79

1.82±2.46

t=16.38

=0.001 New injury severity score

10.61±9.28

2.10±3.04

t=16.55

=0.001 Revised trauma score

7.68±0.56

7.80±0.49

t: 2.97

=0.004 Trauma revised injury severity score

97.12±9.49

99.34±0.66

t=4.51

=0.004 SD: Standard deviation.

Table 4. Correlation analyses between trauma scores and hospitalization time Trauma scores Hospitalization time

ISS

NISS

RTS

TRISS

r=0.36

r=0.42

r=−0.20

r=−0.14

p=0.001 p=0.001 p=0.001 p=0.001

ISS: Injury severity score; NISS: New injury severity score; RTS: Revised trauma score; TRISS: Trauma revised injury severity score.

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Table 5. Trauma scores according to the hospitalization ward Scores

Intensive care unit

Service patients

Result

Mean±SD Mean±SD

Injury severity score

17.50±10.54

7.91±6.78

t=5.48

p=0.001 New injury severity score

20.00±11.02

9.58±8.45

t=5.64

p=0.001 Revised trauma score

6.66±1.30

7.79±0.21

t=5.33

p=0.001 Trauma revised injury severity score

87.75±17.73

98.17±4.42

t=3.58

p=0.001 SD: Standard deviation.

Table 6. Correlation between hospitalization time in ICU and trauma scores Scores Hospitalization time in ICU

ISS NISS RTS TRISS r=0.19

r=0.32

r=−0.32

r=−0.39

p=0.257 p=0.048 p=0.048 p=0.017

ISS: Injury severity score; NISS: New injury severity score; RTS: Revised trauma score; TRISS: Trauma revised injury severity score; ICU: Intensive care unit.

Table 7. Trauma scores among mechanically ventilated and non-mechanically ventilated patients in the intensive care unit Trauma scores

Mechanically ventilated

Non-mechanically ventilated

Result

Mean±SD Mean±SD

Injury severity score

22.20±11.67

12.27±5.89

p=0.013

New injury severity score

24.85±12.00

14.61±6.70

p=0.009

6.12±1.36

7.27±0.93

p=0.005

80.19±21.08

96.16±6.76

p=0.001

Revised trauma score Trauma revised injury severity score SD: Standard deviation.

Table 8. Mechanically ventilation time and trauma scores Trauma scores Mechanically ventilation time

ISS

NISS

RTS

TRISS

r=0.27

r=0.38

r=−0.17

r=−0.56

p=0.243 p=0.096 p=0.467 p=0.010

ISS: Injury severity score; NISS: New injury severity score; RTS: Revised trauma score; TRISS: Trauma revised injury severity score.

values we found that the physiological trauma scores (TRISS) can predict the mechanical ventilation need better than the anatomical trauma scores (RTS, NISS) (p=0.001, p=0.005, p=0.013, and p=0.009, respectively). Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Except TRISS, none of the trauma scores had a significant p value for determination the mechanically ventilation time. There was a strong negative relationship between TRISS and mechanically ventilation time (Table 8). 261

Orhon et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients

DISCUSSION In order to deliver effective, patient centered, efﬁcient, equitable, and timely care to trauma patients by emergency medicine physicians they have to measure the quality of care they deliver with reliable and valid tools. Trauma scoring systems have been developed to estimate the probability of survival, facilitate pre-hospital triage, allow accurate comparison of different trauma populations, evaluate trauma care, compare trauma patient outcomes among hospitals, and organize and improve trauma systems.[11-13]

NISS, RTS, and TRISS) were effective for determining the mechanically ventilation need (p<0.05). When their significance was compared according to their p values it was listed as TRISS, RTS, NISS, and ISS, respectively. TRISS was the only trauma score in our study, which determined the mechanically ventilation time significantly. In spite of the fact that all trauma scores were equally significant for determining the need for ICU, the anatomic scoring systems were more effective. Except ISS, all of the trauma scores could predict the length of stay in ICU.

More than 50 scoring systems have been published for the classiﬁcation of trauma patients in the emergency room and intensive care settings.[14-16] The most frequently used trauma scores are AIS, RTS, TRISS, and ISS. These scores are general trauma scores. In our study, we compared the anatomical scoring systems (NISS, ISS), physiological (RTS), and combined scoring systems (TRISS) among adult trauma patients to ﬁnd out the most effective one.

Fedakar et al.[20] compared the ISS, NISS, GCS, RTS, and TRISS scores among patients with a life-threatening condition descripted according to Turkish criminal law. They found that ISS and NISS were the most appropriate trauma scores. In our study, we found that NISS and ISS could determine the need for ICU better. Whereas TRISS was more successful in determination the mechanically ventilation time and stay in ICU.

Eryilmaz et al.[17] analyzed the patients who were falling from a height and compared the trauma scores (ISS, RTS, NISS, and TRISS). They found the TRISS was most sensitive and specific for predicting the mortality. In our study, we analyzed also the traffic accidents, blunt traumas, penetrating stab-gunshot wounds and we found that the entire trauma scores (ISS, NISS, RTS, and TRISS) were equally significant for the mortality prediction (p<0.05, Table 2).

Lavoie et al.[21] compared NISS with ISS among patients with moderate and severe head trauma for the ICU admission and length of hospital stay, and NISS was found to be better than ISS for the prediction. In our study, ICU need was predicted by all trauma scores significantly, but NISS was more successful. All scores were equally significant in determination hospitalization time.

Güneytepe et al. compared the GCS, RTS, ISS, and TRISS among the elderly trauma patients and found TRISS as the most effective for mortality prediction. Whereas in our study, we analyzed all the individuals over 16 years and found that all of the trauma scores; ISS, NISS, RTS, and TRISS, were significant for the mortality prediction (p<0.05, Table 2). In spite of the fact that the mean age was higher among patients who died, there wasn’t any significant statistical correlation between age and survival rate (p>0.05, Table 3). This could be due to the low mortality rate, only eight patients. [18]

Aydin et al. compared the efficacy of ISS and NISS for predicting the mortality in patients with multiple trauma and searched the answer if ISS could take the place of NISS in TRISS model. At the end of the study, they didn’t found any significant difference between ISS and NISS for predicting mortality and also NISS was not an alternative for ISS in TRISS model. In our study, we compared both anatomical, physiological and combined trauma scores (ISS, NISS, RTS, and TRISS) for the mortality prediction and all of them were equal to each other for the prediction of mortality (p<0.05, Table 2). [3]

Honarmand[19] analyzed the effectivity of ISS and NISS among the trauma patients who were admitted to ICU. They found that NISS was better for determining “Need for intubation” and “mechanical ventilation.” In our study, all scores (ISS, 262

Schluter et al.[22] analyzed the predictivity of TRISS among the trauma patients to estimate the length of hospital stay. The result showed that TRISS was not sufficient and reliable to predict the length of hospital stay and useable for the followup. In our study, all trauma scores were statistically significant for the estimation of hospitalization time. Like in our study, Eryilmaz et al.[23] compared anatomic and physiological scores in terms of mortality and they did not found superiority to each other. Bilgin et al.[24] have analyzed trauma scores effectivitiy for writing effective forensic reports among trauma victims. Although all trauma scores were significant the ISS method was found to be more successful. According to our results anatomical scores (NISS and ISS) exhibited the need for ICU, and TRISS determinates the mechanical ventilation need and length of ICU treatment better. Between the anatomical scoring systems NISS predictive power was relatively higher than ISS in our study in terms of morbidity (hospital and ICU admission requirements, length of stay in ICU, mechanical ventilation need). This can be while the serious injuries in the same region are preferred than a slight injury in a different body region for NISS calculation. NISS and ISS predictive power were equal to each other in terms of length of hospital stay. Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Orhon et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients

There was not a statistically significant relationship between mortality and age or injury mechanism. This could be due to the low mortality rate, eight patients. Furthermore, the mortality rate between genders could not be made while all of the patients who died were male. All of the victims and the majority of trauma patients (76.1%) are male. This could be while men live more active, travel more, most of the drivers are men, and they are present more in the trauma environments. Osler et al.,[25] summarizes the algorithm used for estimation of prognosis as; anatomical injury + physiological injury + patients reserve. Accordingly, it is difficult to predict the prognosis only with the anatomical and physiological injury scores. In addition, age, existing chronic diseases, and possible genetic predispositions varies patient’s survival rate in trauma patients. In spite of the fact that this could be a better formulation for estimation the prognosis, it doesn’t differs the results of our trauma scores effectivity. Age and trauma mechanism factors are considered in TRISS, opposed to other score calculations. This enables both anatomical and physiological trauma determination which can make TRISS superior to other trauma scores. As a result of our research, TRISS has established ICU length of stay and mechanical ventilation need better. It is accepted that ISS results are close to TRISS, and that’s why ISS is used commonly for TRISS in practice. This is not supported by our study.

Acknowledgments At the end of our study, we found that all of the trauma scores were equal significant for predicting the hospitalization ward and mortality, mechanically ventilation and hospitalization need. Only in predicting the ICU hospitalization time TRISS was better. To determine the superiorities of the trauma scores better, multicentric studies with more patients can be made. Furthermore, new trauma scores with different parameters can be designed. Conflict of interest: None declared.

REFERENCES 1. Özgüç H, Kaya E, Korun N. Factors Affecting Outcome In The Resuscitation of Trauma. Ulus Travma Acil Cerrahi Derg 1995;1:51-8. 2. Dur A, Cander B, Koçak S, Girişgin S, Gül M, Koyuncu F. Multiple trauma patients and trauma scoring systems in emergency-intensive care unit. JAEM 2009;8:24-27. 3. Aydin SA, Bulut M, Ozgüç H, Ercan I, Türkmen N, Eren B, et al. Should the New Injury Severity Score replace the Injury Severity Score in the Trauma and Injury Severity Score? Ulus Travma Acil Cerrahi Derg 2008;14:308-12. 4. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score:

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a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96. 5. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987;27:370-8. 6. Hurst James M. Trauma: an overview. In: Rippe JM, Irwin RS. editors. Intensive care medicine. 5 th ed. Boston: Little, Brown and Company; 1991. p.1455-6. 7. Roberton C, Redmond AD. The management of major trauma. 6th ed. Oxford, USA: Oxford University Press; 1994. 8. Yağmur Y, Güloğlu C, Uğur M, Akkuş Z, Elik Y. Evaluatıon Of Patients With Multiple Injuries: Comparison Of Injury Severity Score And Revised Trauma Score. Ulus Travma Acil Cerrahi Derg 1997;3:73-7. 9. Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries. J Trauma 1994;37:962-8. 10. İhtiyar E, Ünlüoğlu I, Şahin A, Caga T, Karahüseyinoğlu E. The Evaluation Of Multi - Trauma Patients with GCS, TS, AIS At Osmangazi University Faculty Of Medicine Emergency Service: Prospective Evaluation Of 734 Patients. Ulus Travma Acil Cerrahi Derg 1998;4:176-9. 11. Veenema KR, Rodewald LE. Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center. Ann Emerg Med 1995;25:175-81. 12. Fallon WF Jr, Barnoski AL, Mancuso CL, Tinnell CA, Malangoni MA. Benchmarking the quality-monitoring process: a comparison of outcomes analysis by trauma and injury severity score (TRISS) methodology with the peer-review process. J Trauma 1997;42:810-7. 13. Moini M, Rezaishiraz H, Zafarghandi MR. Characteristics and outcome of injured patients treated in urban trauma centers in Iran. J Trauma 2000;48:503-7. 14. Esme H, Solak O, Yurumez Y, Yavuz Y, Terzi Y, Sezer M, et al. The prognostic importance of trauma scoring systems for blunt thoracic trauma. Thorac Cardiovasc Surg 2007;55:190-5. 15. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623-9. 16. Bouillon B, Lefering R, Vorweg M, Tiling T, Neugebauer E, Troidl H. Trauma score systems: Cologne Validation Study. J Trauma 1997;42:6528. 17. Eryılmaz M, Durusu M, Menteş Ö, Özer T, Kılıç S, Ersoy G, et al. Comparison of trauma scores for adults who fell from height as survival predictivity. Turk J Med Sci 2009;39:247-52. 18. Güneytepe Üİ, Aydın ŞA, Gökgöz Ş, Özgüç H, Ocakoğlu G, Aktaş H. The factors influencing the mortality in elderly trauma patients and scoring systems. Uludag Medical Journal 2008;34:15-9. 19. Honarmand A, Safavi M. The new Injury Severity Score: a more accurate predictor of need ventilator and time ventilated in trauma patients than the Injury Severity Score. Ulus Travma Acil Cerrahi Derg 2008;14:1107. 20. Fedakar R, Aydiner AH, Ercan I. A comparison of “life threatening injury” concept in the Turkish Penal Code and trauma scoring systems. Ulus Travma Acil Cerrahi Derg 2007;13:192-8. 21. Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The Injury Severity Score or the New Injury Severity Score for predicting intensive care unit admission and hospital length of stay? Injury 2005;36:477-83. 22. Schluter PJ, Cameron CM, Davey TM, Civil I, Orchard J, Dansey R, et al. Using Trauma Injury Severity Score (TRISS) variables to predict length of hospital stay following trauma in New Zealand. N Z Med J 2009;122:65-78.

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Orhon et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients 23. Eryilmaz M, Durusu M, Cantürk G, Menteş MO, Ozer MT, Cevik E, et al. Role of anatomic and physiologic trauma scoring systems in forensic cases. Ulus Travma Acil Cerrahi Derg 2009;15:285-92. 24. Bilgin NG, Mert E, Camdeviren H. The usefulness of trauma scores in

determining the life threatening condition of trauma victims for writing medical-legal reports. Emerg Med J 2005;22:783-7. 25. Osler T, Rutledge R, Deis J, Bedrick E. ICISS: an international classification of disease-9 based injury severity score. J Trauma 1996;41:380-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Travma hastalarında mortalite ve morbidite öngörüsünde travma skorlamalarının karşılaştırılması Dr. Reyhan Orhon,1 Dr. Şevki Hakan Eren,2 Dr. Şule Karadayı,2 Dr. İlhan Korkmaz,2 Dr. Abuzer Coşkun,2 Dr. Mehmet Eren,3 Dr. Nurkay Katrancıoğlu4 Gaziantep Devlet Hastanesi, Acil Tıp Kliniği, Gaziantep; Cumhuriyet Üniversitesi Hastanesi, Acil Servis, Sivas; Ankara Yenimahalle Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara; 4 Cumhuriyet Üniversitesi Hastanesi, Kalp Damar Cerahisi Servisi, Sivas 1 2 3

AMAÇ: Bu çalışmada travmalı olgularda anatomik ve fizyolojik skorlama sistemleri (TRISS, RTS, ISS, NISS) birbiriyle karşılaştırılarak, mortalite ve morbiditeyi hangi travma skorunun en doğru ve güvenilir bir şekilde tahmin ettiğinin araştırılması amaçlandı. GEREÇ VE YÖNTEM: Çalışmamız, üniversite hastanesi acil servisi’ne sekiz aylık dönemde travma nedeniyle başvuran 633 hastanın kesitsel olarak incelenmesi yöntemiyle yapıldı. Çalışmaya 16 yaş ve üzerindeki künt ve penetran travmalı (trafik kazası, ateşli silah yaralanması, delici-kesici alet yaralanması gibi) hastalar alındı. BULGULAR: Hastaların geliş anındaki travma skorları (ISS, NISS, RTS, TRISS) hesaplandı. Mortalite tahmini için ortalama travma skoru hesaplandı ve p değeri tümü için eşit bulundu (p=0.001).Travma skorları yoğun bakım ünitesinde yatış süresi için analiz edildiğinde, NISS, RTS ve TRISS skorlama değerleri anlamlı (p=0.048, p=0.048 and p=0.017 sırasıyla), ISS skorlaması anlamlı değildi (p=0.257). Sadece TRISS skorlama sisteminin yoğun bakım ünitesi hastalarında mekanik ventilasyonda kalma süresini tahmin etmede iyi bir belirleyici olduğu bulundu (p=0.01). TARTIŞMA: Sonuç olarak hastaneye yatış gereksinimini ve yoğun bakımda yatış gereksinimini anatomik skorlama sistemleri olan NISS ve ISS’nin; yoğun bakımda yatış süresi ve mekanik ventilatörle ilgili süreci ise anatomofizyolojik skor olan TRISS’nin daha iyi öngördüğünü tespit ettik. Anahtar sözcükler: Morbidite; mortalite; travma; travma skoru. Ulus Travma Acil Cerrahi Derg 2014;20(4):258-264

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doi: 10.5505/tjtes.2014.22725

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ORIGIN A L A R T IC L E

Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis Teoman Eskitaşcıoğlu, M.D., İrfan Özyazgan, M.D., Atilla Coruh, M.D., Galip K Günay, M.D., Mehmet Altıparmak, M.D., Yalcin Yontar, M.D., Fatih Doğan, M.D.† Department of Plastic Reconstructive and Aesthetic Surgery, Erciyes University Faculty of Medicine, Kayseri Current affiliation: Department of Plastic Reconstructive and Aesthetic Surgery, Adıyaman University Faculty of Medicine, Adıyaman

†

ABSTRACT BACKGROUND: The purpose of the present study was to retrospectively analyze the patients’ data presented with Fournier’s gangrene (FG), to compare obtained data with the literature and to investigate the role of “trauma” in the etiopathogenesis. METHODS: A retrospective study was conducted on 126 patients with FG that consulted to our department. RESULTS: There were 76 male and four female patients. The mean age of the patients was 53.5±13.6 years. The most common presentation of patients was swelling (n=74). The scrotum has been shown to be the most commonly affected area in the patients (n=75). Diabetes mellitus was the leading predisposing factor and trauma was the leading responsible cause for FG. Escherichia coli was the most frequently identified microorganism (n=43, 53.75%). Primary closure was the most common technique used for all patients. Three patients exhibited a mortal course due to sepsis and multi-organ failure. CONCLUSION: FG still has a high mortality rate. Rapid and correct diagnosis of the disease can avoid inappropriate or delayed treatment and even death of the patient. The healthcare professionals should be aware that any trauma in the perineal region could lead to FG. Key words: Fournier’s gangrene; reconstruction; trauma.

INTRODUCTION Fournier’s gangrene (FG) is an infectious necrotizing fasciitis of the perineal region that progressively spreads along the fascial planes. The necrotizing infection leads to obliterative endarteritis of dermal and subdermal perforating vessels resulting in gangrene of the subcutaneous tissue and the overlying skin.[1] Colorectal region, genitourinary tract and cutaneous flora are the most common sources of the bacterial pathogens in FG.[2] The infection is frequently polymicrobial and synergistic with several aerobic, or anaerobic microorganisms including Escherichia coli, Klebsiella, Staphylococcus, Streptococcus, Proteus, and Pseudomonas species.[3,4]

Risk factors for FG include increased age, ethanol abuse, immunosuppressive conditions such as diabetes mellitus (DM), steroid usage, malignancies, etc.[5-16] Chronic renal failure, prehospital delay time, extent of the affected area, serum-blood urea nitrogen and creatinin level are some of the factors that affected the prognosis of the disease.[7] FG is associated with a mortality rate of 9-43%.[17-24] The purpose of the present study was to retrospectively analyze the patients’ data presented with FG, to compare obtained data with the literature and to investigate the role of “trauma” in the etiopathogenesis of FG.

MATERIALS AND METHODS Address for correspondence: Teoman Eskitaşcıoğlu, M.D. Erciyes Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Melikgazi, 38039 Kayseri, Turkey Tel: +90 352 - 207 66 66 E-mail: teskitascioglu@gmail.com Qucik Response Code

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A 17-year retrospective study was conducted on 126 patients with FG that consulted to the Department of Plastic and Reconstructive Surgery of Erciyes University Medical Faculty between January 1997 and May 2013. Of the patients, 80 with available hospital records were included in the study. The diagnosis of FG was made on the basis of clinical findings and anamnesis of the patients. Radiologic examinations were performed for the diagnosis of FG in suspected clinical presentations. Patients’ data regarding age, sex, presenting features at hospital admission, anatomic distribution, pre-hospital delay 265

Eskitaşcıoğlu et al. Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis

time, predisposing factors, etiologic causes, treatment modalities, hospitalization time, and mortality rate were evaluated retrospectively. Pre-hospital delay was defined as the time from the onset of symptoms until hospital admission. Clustered data were analyzed statistically by using software package (SPSS for Windows, release 20.0.0; IBM, Chicago, IL, USA). This study was approved by the “Institutional Review Board of Erciyes University Medical Faculty.”

RESULTS Age and Sex There were 76 male (95%) and 4 female (5%) patients with a male to female ratio of 19:1. The age of the patients ranged from 19 to 82 years, and the mean age was 53.5±13.6 years. The highest incidence of FG was observed in the age group of 50-60 years (n=25, 31.25%) (Fig. 1) and the most affected patients were the males in this age group.

Presenting Features at Hospital Admission The most common presentations of patients were swelling (n=74, 92.5%), pain (n=42, 52.5%), hyperemia (n=21, 26.25%), purulent discharge from the affected area (n=18, 22.5%), and fever (n=16, 20%) (Table 1). Ultrasonography was the primary chosen diagnostic tool in 33 patients (41.25%) with suspected clinical presentations. Findings typically included marked thickening of the scrotal skin, subcutaneous gas, increased blood supply to the epididymis and testis, increased peritesticular fluid, abscess and hematoma formation.

Anatomic Distribution The scrotum has been shown to be the most commonly affected area in the patients (n=75, 93.75%). Other affected areas, in decreasing order of frequency were perianal region (43.75%), penis (22.5%), abdominal wall (6.25%), gluteal region (6.25%), pubis (5%), inguinal region (3.75%), vulva (3.75%), sacral region (1.25%), and thigh (1.25%) (These numbers add to more than 100% because some patients had 30

Female Male

n %

Swelling

74 92.5

Pain

42 52.5

Hyperemia

21 26.25

Purulent discharge

Fever

16 20

Constipation

4 5

Urinary retention

Urinary incontinence

3.75

Fecal incontinence

1.25

15 10

Pre-hospital Delay Time The mean pre-hospital delay time of the patients was 5.48±4.55 days (range, 1-25 days). The duration of symptoms before hospital admission was 1 day in 11 patients (13.75%), 2-4 days in 31 patients (38.75%), 5-7 days in 24 patients (30%), and more than 7 days in 14 patients (17.5%) (Fig. 2).

Predisposing Factors Of the patients, 62 had one or more than one predisposing factor for FG. DM (42.5%), smoking (27.5%), and hypertension (16.25%) were the leading ones that followed by benign prostatic hyperplasia (BPH), coronary artery disease (CAD), chronic obstructive pulmonary disease, paraplegia, hemiplegia, ethanol abuse, chronic renal insufficiency, pancytopenia, cachexia, Leriche syndrome, and familial Mediterranean fever, respectively (Table 2).

Etiologic Causes Etiologic causes were identified in 41 patients (51.25%). Trauma (n=20, 25%), colorectal diseases (n=16, 20%), and genito35 30 25 20 15 10 5 0

10-20 21-30

31-40 41-50 51-60 61-70 71-80 81-90 Age

Figure 1. Distribution of patients according to age and sex.

22.5

more than one affected area). The incidence of the abdominal wall involvement was 75% in female (3/4) and 2.6% in male patients (2/76). Unilateral necrotic testis was observed in six patients (7.5%).

266

Finding

No. of patients

Table 1. Initial presentations of patients with Fournier’s gangrene

1st

2nd-4th

5th-7th 8th-10th 11th-14th Days

>14th

Figure 2. Distribution of patients according to time of hospital admission.

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Eskitaşcıoğlu et al. Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis

Table 2. Predisposing factors of patients with Fournier’s gangrene

Table 3. Identified etiologic factors for Fournier’s gangrene Etiologic factor

Colorectal diseases

11.25

Anal fissure

3.75

Perianal fistula

2.5

Predisposing factor

Diabetes mellitus

42.5

Smoking

22 27.5

Hypertension

13 13.75

Benign prostatic hyperplasia

Colorectal carcinoma

2.5

Coronary artery disease

8.75

Genitourinary disorders

6.25

Chronic obstructive pulmonary disease

7.5

Urethral stricture

Hemorrhoid

5 6.25

Bladder carcinoma

1.25

Paraplegia

4 5

Trauma

20 25

Hemiplegia

2 2.5

Non-surgical trauma

Ethanol abuse

2.5

Chronic perineal irritation

Chronic renal insufficiency

1.25

Falling down

1.25

Pancytopenia

1 1.25

Burn injury of lower extremities

Cachexia

1 1.25

Surgical trauma

Leriche syndrome

1.25

Familial Mediterranean fever

1.25

Hemorrhoidectomy

urinary disorders (n=5, 6.25%) were the responsible causes for FG. Furthermore, there were no etiological factors in 39 patients (48.75%). In total, perianal abscess was the leading etiologic factor for FG (n=9, 11.25%). Traumatic factors were divided into two main groups according to the mechanism of injury: (1) surgical and (2) nonsurgical trauma. Of the patients, 12 had undergone invasive therapeutic procedures within 2 months prior to disease onset including drainage of perianal abscess, hemorrhoidectomy, incisional hernia repair, femoral hernia repair, caesarean section, surgery for penetrating intestinal injury, flap closure of sacral pressure sore, balloon dilatation for BPH, and transurethral resection of prostate (TUR-P). One of our patients had burn injury of the lower extremities that resulted in unhealed burn wound and one with Leriche syndrome had a trauma that caused by falling on to the hip. Among the patients, farmers were the most common occupational group (n=13, 16.25%) in whom six of them had a history of chronic perineal irritation due to pricking of thorn (Table 3).

Microbiology and Antibiotherapy Positive bacteriologic cultures were obtained in 74 (92.5%) patients and the infection was polymicrobial in 14 patients (17.5%). E. coli was the most frequently identified microorganism (n=43, 53.75%) that followed by; Staphylococcus aureus, Enterococcus, Acinetobacter baumani, Staphylococcus epidermidis, Streptococcus spp., Proteus, Citobacter, Bacteriodes, Klebsiella oxycata, and Prevotella, respectively (Table 4). Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Perianal abscess

Drainage of perianal abscess

1.25

3.75

2.5

Hernia repair

2.5

Flap closure of sacral pressure sore

1.25

Surgery for penetrating intestinal injury

1.25

Caesarean section

1.25

Balloon dilatation for BPH

1.25

Trans-urethral resection of prostate

1.25

Total

41 51.25

BPH: Benign prostatic hyperplasia.

Table 4. Identified causative pathogens of patients with Fournier’s gangrene Microorganism

n %

Escherichia coli

43 53.75

Staphylococcus aureus

12 15

Enterococcus

9 11.25

Acinetobacter baumani

5 6.25

Staphylococcus epidermidis

5 6.25

Other Streptococcus spp.

4 5

Proteus

4 5

Citobacter

1 1.25

Bacteroides

1 1.25

Klebsiella oxycata

1 1.25

Prevotella

1 1.25

All patients received empiric antibiotic regimen intravenously including the combination of a third-generation cephalospo267

Eskitaşcıoğlu et al. Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis

rin and metronidazole. The most preferred antibiotics according to antibiotic susceptibility results were ciprofloxacin (n=40) and clindamycin (n=34).

and multi-organ failure. The mortality rate of patients with abdominal wall involvement was 40% (2/5) in whom one of them was male and one was female.

Surgical Management

DISCUSSION

All patients underwent aggressive surgical debridement of the necrotic tissues by the departments of general surgery or urology, averaging 1.55±1.15 operations/patient (range, 1-8 debridements). Serial debridement of the necrotic tissues was required for 24 patients (30%). Time to initial debridement from the disease onset was ranged from 1 to 29 days with a mean value of 6.05 days. Debridement was performed in the same day of hospital admission in 60 patients (75%) (Fig. 3).

The scrotal gangrene was published for the first time by Baurienne in an article named “Sur une Plaie contuse qui

Orchiectomy was carried out unilaterally in six patients (7.5%) due to presence of necrotic testis. Radical vulvectomy was performed in one of the female patients due to grossly necrotic external genitalia.

Ornidazole 10

Colostomy was performed in 12 patients (15%) for fecal diversion who had a high risk of fecal contamination in the presence infected anal sphincter, or large perianal defects. Urinary diversion is provided by suprapubic cystostomy in seven patients (8.75%) because of urethral involvement that resulted in urinary extravasation.

Metronidazole 5

We could not apply any reconstructive technique in one of the consulted patients due to rapid mortal course. The distribution of the reconstructive techniques shows that performing primary closure alone (n=27, 33.75%) was the most common technique used for all patients. The others were listed in Table 6.

Ertapenem 2

Table 5. Preferred antibiotic according to antibiotic susceptibility results Antibiotic n Ciprofloxacin 40 Clindamycin 34 Cephaperazon-sulbactam 8 Amicasin 5 Imipenem 5 Piperacillin-tazobactam 5 Ampicillin-sulbactam 4 Teicoplanin 4 Aztreonam 2 Cephtriaxon 2 Ceftazidime 1 Cefixime 1 Gentamicin 1 Neutromycin 1 Polymyxin E

Hospitalization Time The mean hospitalization time of the patients was 34.78±18.83 days (range, 8-106 days). It was 33.73±17.30 days (range, 8-103 days) for survivors, 61.6±38.9 days (range, 33-106 days) for non-survivors.

Technique

n %

Primary closure

33.75

Scrotal flap

13.75

Primary closure + skin grafting

12.5

Skin grafting

Scrotal flap + skin grafting

7.5

Pudendal thigh fasciocutaneous flap

6.75

Scrotal flap + primary closure

Gracilis musculocutaneous flap

2.5

Medial thigh flap

2.5

Super-thin groin island flap

2.5

Abdominal advancement flap + skin grafting

2.5

Total

79 100

Mortality Of the patients, three exhibited a mortal course due to sepsis

No. of patients

Table 6. Applied reconstructive techniques for closure of the cutaneous defects

1st

2nd

3rd Days

4th

5th

Figure 3. Time to initial debridement from the disease onset.

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s’estterminée par le sphacele de tout le scrotum” (1764).[25] Jean Alfred Fournier, the French venereologist after whom the term “FG” was named, reported five cases that presented with fulminant gangrene of the scrotum and penis (1883-84).[26,27] Fournier described the most important criteria of the disease as sudden onset of painful scrotal edema in healthy young males, rapid progression into the gangrene and absence of an etiologic cause.[26,27] Since then, the epidemiologic properties, clinical features and incidence of FG have changed dramatically. The incidence of the disease has increased toward the end of the 20th century. In the literature, there were 209 reported cases of FG from 1764 through 1950. It was 177 from 1951 through 1978, 449 from 1979 through 1988; and 1100 from 1989 through 2000.[3,28] Increased incidence of chronic illness as a result of the aging population may be the explanation for the rise of FG now-a-days.[3] FG is not a disease limited to young males as originally thought by Fournier.[26,27] The previous reports suggested the highest incidence of male patients in the 6th decade of life. [29-33] Even with the lower incidence rates, the disease was found in females and in all age groups of childhood including newborn and infancy periods.[33-40] The results of the present report were in agreement with the literature regarding age and sex. The most affected patients were the males aged between 50 and 60 years. There was predominance of male patients over females, with a male:female ratio of 19:1, which was reported between 2.5:1 and 171:0 in the literature.[3,5,40-42] According to Ferreira et al., the incidence of FG is lower in female patients because of better drainage of the genital secretions due to the vaginal tract.[29] But, once the FG is established, the female gender, which is an advantage in terms of disease incidence, becomes a risk factor in terms of mortality. The direct extension of the infection intra-abdominally through the Fallopian tubes may yield to fatal peritonitis and multi-organ failure in female patients.[43] In consistent with this data, abdominal involvement (75%) and mortality rate of female patients (25%) were higher than males in the present report. FG is no longer considered idiopathic since the pathologic features of the disease are well-defined and portals of entry for causative microorganisms are well-known. There are reported etiologic causes such as colorectal carcinoma,[44,45] sigmoid carcinoma,[46] perianal/perirectal abscess,[5,29,47,48] ruptured appendicitis,[49,50] sigmoid diverticulitis,[51] Bartholin gland abscess,[2,5,6] renal abscess,[52] urethral stone,[53] urethral stricture,[13,54] etc. The most common etiologic cause was perianal abscess (11.25%) in a total of our cases that followed by chronic perineal irritation (7.5%) and surgically drainage of perianal abscess (3.75%) (Table 3). In the literature, urethral catheterization,[55] vasectomy,[56,57] prostate biopsy,[58] neonatal circumcision,[35,38] hernia reUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

pair,[59,60] hemorrhoidectomy,[61] episiotomy,[62-64] and hysterectomy[43] were reported as surgical; anal intercourse,[65] coitus,[26,66] urethral[67,68] or anal foreign body,[69,70] penile selfinjection with cocaine,[71] heroin injection into the femoral vessels[22] and mechanical erection aid device usage[4] were reported as the non-surgical traumatic causes for FG. The source of the pathogens may be colorectal region, genitourinary tract or cutaneous flora with respect to the mechanism of trauma. In the present report, traumatic factors were responsible in 20 patients (25%). Twelve cases developed FG after invasive procedures within 2 months prior to disease onset including drainage of perianal abscess, hemorrhoidectomy, incisional hernia repair, femoral hernia repair, surgery for penetrating intestinal injury, flap closure of sacral pressure sore, balloon dilatation for BPH, and TUR-P. Furthermore, there was a female patient with extended abdomino-perineal involvement of FG in the week following a cesarean section (Table 3). Interestingly, six of the patients that engaged in farming defined chronic perineal trauma due to pricking of thorn while working in the field. One of our patients was referred to the emergency department with fever, pain, and swelling with gangrenous perineal skin. He had undergone aortobifemoral by-pass grafting for Leriche syndrome five months ago and had a trauma that was caused by falling on to hip in the previous week. After wound debridement, a modified pudendal thigh flap was performed in the treatment of the perineal defect successfully.[72] Leriche syndrome is an aortoiliac occlusive disease with a decreased blood flow to the pelvic region[73,74] in which a successful aortobifemoral by-pass grafting restored the circulation of the lower extremities to an almost normal state. In this case, diminished blood flow to the pelvic region due to by-pass occlusion and inoculation of the cutaneous flora to the deeper tissues as a result of pelvic trauma were considered as the triggering factors for FG. This case was the excellent example for the association of vascular occlusive diseases and trauma in the etiopathogenesis of FG. In our opinion, as a result of surgical or non-surgical trauma, seeding the causative microorganisms to the subcutaneous tissues due to disruption of skin and mucous membranes’ integrity and extension of the infection through the fascial planes is the physiopathological explanation for FG. Additionally, comorbidities that resulted in immunosuppression, tissue ischemia, and oxygenation disturbance increase tendency to the disease. The studies concerning the effect of trauma in the etiopathogenesis of FG date back to the 18th century. In 1764, Baurienne reported a 14-year-old case with FG secondary to being gored by an ox’s horn. The patient presented with clinical signs and symptoms directly attributable to FG including pain and gangrenous scrotum. The patient recovered after a prolonged hospital course with secondary intention of the wound following serial debridements.[25,75] 269

Eskitaşcıoğlu et al. Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis

Identified risk factors for FG are as follows: increased age, ethanol abuse, immunosuppressive conditions such as DM, steroid usage, malignancies etc.[5-16] According to the literature,[6,16] the most frequent pre-existing comorbidity was DM in the present report (n=34, 42.5%). Controversy still exists as to whether or not DM is associated with poor prognosis in FG. In contrast to previous reports[5,16,76] Steinman et al.[77] defined DM as a statistically significant factor when associated with bad prognosis. Immunocompromision due to impairment of neutrophil functions[78] and tissue ischemia due to micro- and macro-angiopathies, increase tendency to FG and other infectious diseases in diabetic patients.[12] In addition, 28 of our patients had comorbidities including smoking, CAD, ethanol abuse, Leriche syndrome, and FMF that leaded to vascular occlusive diseases, tissue ischemia and decreased host defense, as well as DM. FG is a polymicrobial and synergistic infection in which aerobic and less frequently anaerobic microorganisms may be identified.[2] According to the literature,[2,7,44,79,80] E. coli was the most frequently identified microorganism (n=43, 53.75%) in the present report. Due to the rapid progression of necrotizing infection, use of double or triple wide-spectrum antibiotics initially are necessary to bring the infection under control.[48] The most preferred antibiotics according to antibiotic susceptibility results were ciprofloxacin and clindamycin in the present report (Table 5). Scrotum was the most affected anatomic location that followed by perianal region in this series. As described in the literature,[56,81] abdominal wall (n=5, 6.25%), and thighs (n=1, 1.25%) were areas in which the necrotizing infection was observed less frequently. Furthermore, the incidence of the abdominal wall involvement was higher in females when compared with males. The necrotizing process may extend to the abdominal wall due to the continuity of perineal colles’ and abdominal Scarpa’s fascia.[6] In agreement with the report of Unal et al.,[78] mortality rate was higher in patients with abdominal wall involvement (40%). The explanation may be that involvement of the abdominal wall leads to larger defects that resulted in worst clinical condition, need for more challenging reconstructive techniques, and thus higher morbidity and mortality rate. The testes are rarely affected in FG due to their separate blood supply[2] and incidence of orchiectomy due to gangrenous testes ranges 10-30% in the literature.[8,15,21] In six of our cases, testes were evaluated as necrotic that required unilateral orchiectomy. In our serial, preventive colostomy was performed in 12 patients (15%) who had a sphincteric infection or high-risk of fecal contamination due to large perianal defects. In addition, suprapubic cystostomy was performed in 7 (8.75%) of our patients due to urethral involvement and urinary extravasation. Despite of reported higher mortality rates in patients in whom colostomy and/or cystostomy were performed,[41,82,83] non-survivors of this series had neither colostomy, nor cystostomy. 270

The diagnosis of FG is generally based on clinical findings during hospital admission. Radiologic examinations such as ultrasonography, plain radiographs or computed tomography may assist as a diagnostic tool. In the present report, ultrasonography was chosen primarily to support the diagnosis in suspected clinical presentations. Morrison et al. reported the pathognomonic ultrasonographic findings for FG as the thickening of the scrotal skin and subcutaneous gaseous accumulations.[84] Following diagnosis, immediately performed surgical debridement of the necrotic tissues, systemic anti-biotherapy and adequate fluid replacement are of the essence in the treatment of FG. The main purpose of the surgical debridement is to remove devitalized tissues and to prevent the progression of the necrotizing infection and sepsis. The necrotic tissues should be debrided aggressively until viable tissues were encountered. [85] Aggressive surgical debridements can result in major perineal, thigh, or abdominal skin loss, which poses a significant challenge to reconstructive surgeons.[86] The timing of surgical debridement in cases of FG is an important factor for the prognosis of the disease. Pre-hospital delay time and ability of the patient to tolerate a surgical procedure are some of the factors that affect the timing of surgical procedure. In the present report, time to initial debridement was 5.76±4.58 days for survivors and 6.66±8.14 days for non-survivors that showed statistically no significant difference. Delayed hospital admission was associated with the higher mortality rate in the previous reports.[5,41,47,81] However, Laor et al.[87] and Moorthy et al.[88] affirmed that there is presently no strong evidence for either acute or delayed hospital admission with the prognosis of the disease. The pre-hospital delay time was not significantly different between survivors (5.45±4.50days) and non-survivors (6±5.7 days) in the present report. Reported mortality rates of FG are ranged between 9% and 43% in the literature.[14,17-24] Lower mortality rate of the present report (3.75%) may be explained by the unconsulted patients from other departments due to rapid fatal course. Cutaneous defects due to FG require challenging aesthetic and functional reconstruction. Skin grafts, muscle flaps, musculocutaneous flaps, and fascia-cutaneous flaps[89,90] have been used for this purpose, but a satisfactory functional and esthetic outcome is rarely achieved. The extent and the location of the cutaneous defect are the crucial factors in the selection of the most appropriate treatment option.[91] In the present report, variable reconstructive techniques were performed in order to close the cutaneous defects. Primary closure (n=27, 33.75%) was the most common technique used for all patients, followed by the skin grafting, Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

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scrotal flap, pudendal thigh flap, super-thin groin island flap, gracilis musculocutaneous flap, abdominal advancement flap, and groin flap, respectively (Table 6). It has been suggested that using skin grafts to reconstruct larger defects will reduce the hospitalization time and provide a thinner covering.[89] In addition, the texture of external genitalia that provided by skin graft are usually far from being natural due to the possibility of scar contracture and synechiae. In our opinion, skin grafting is useful due to its simplicity and reliability and helpful in thermoregulation of the testes. Forming scrotal neo-septum by suturing the sides of the testes facing each other and covering them with a skin graft provide more natural-looking results in cases with bilaterally exposed testes (Fig. 4).

tive technique in the closure of extensive perineal defects and maintains almost a suitable, thin cover. Large defects can be closed by this technique without achieving a bulky flap formation in the scrotal and penile region. On the other hand, it provides significant benefit in thermoregulation of the testes. The disadvantage of this flap is that it requires tissue expansion and two operative sessions for closure of the defect. [91] We performed this flap in two of our patients without any complications. The gracilis musculocutaneous flap was performed in two of our patients with large defects of the perineal region. The main disadvantage of the gracilis musculocutaneous flap is the bulky nature of the flap and the necessity to use a functional muscle.[93]

Scrotal flap is useful for repairing small to medium-sized defects of the scrotum and provide a perfect cover for the exposed testes in terms of aesthetics and functionality. Thin and unstretched coverage is obtained by dissecting the scrotal skin laterally. In cases with inadequate scrotal flap dimension, testes were buried in thigh pockets for facilitating the closure of the wound. Salvage of the testes by burial is associated with detrimental psychological effects and has been shown to have a negative impact on spermatogenesis.[92]

Pudendal thigh flap is satisfactory functionally and cosmetically. Some of its advantages are that (a) ability to easy application, (b) resulting in an inconspicuous linear scar in the donor site, and (c) having a reliable blood supply.[94] We used pudendal thigh flap in seven of our patients in this series. We only experienced minimal necrosis in the distal end of the flap in one patient, minimal wound dehiscence in two patients that healed by conservative means.

Bilaterally expanded super-thin groin island flap is an alterna-

FG still has a high mortality rate despite aggressive surgical

Conclusion

(a)

(b)

(c)

(d)

Figure 4. A patient with a scrotal split-thickness graft. (a) Pre-operative view of testes and scrotum. (b) Intra-operative view of testes that sutured together in order to form the scrotal neo-septum. (c) Intra-operative view of testes after covering with split-thickness skin graft. (d) One year post-operative view of scrotum.

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debridements, modern antimicrobial drugs and intensive care units. Rapid and correct diagnosis of FG can avoid inappropriate or delayed treatment and even death of the patient. The healthcare professionals should be aware that any trauma in the perineal region could lead to FG. Conflict of interest: None declared.

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64. Sutton GP, Smirz LR, Clark DH, Bennett JE. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66:733-6. 65. Bernstein SM, Celano T, Sibulkin D. Fournier’s gangrene of the penis. South Med J 1976;69:1242-4.

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86. Hesselfeldt-Nielsen J, Bang-Jensen E, Riegels-Nielsen P. Scrotal reconstruction after Fournier’s gangrene. Ann Plast Surg 1986;17:310-6. 87. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier’s gangrene. J Urol 1995;154:89-92. 88. Moorthy K, Rao PP, Supe AN. Necrotising perineal infection: a fatal outcome of ischiorectal fossa abscesses. J R Coll Surg Edinb 2000;45:281-4.

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Eskitaşcıoğlu et al. Experience of 80 cases with Fournier’s gangrene and “trauma” as a trigger factor in the etiopathogenesis 89. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier’s gangrene. Burns 2003;29:857-62. 90. Horton CE, Stecker JF, Jordan GH. Genital reconstruction following trauma. In: McCarthy JG, editor. Plastic surgery. New York: W.B. Saunders; 1990. p. 4226-39. 91. Dogan F, Eskitascioglu T, Altiparmak M, Özyazgan İ. Bilateral super thin groin island flap for penile, scrotal and pubic reconstruction after

Fournier’s gangrene. Eur J Plast Surg 2010;34:497-9. 92. Datubo-Brown DD. Alternative techniques for scrotal reconstruction. Br J Urol 1990;65:115-7. 93. Kayikçioğlu A. A new technique in scrotal reconstruction: short gracilis flap. Urology 2003;61:1254-6. 94. Monstrey S, Blondeel P, Van Landuyt K, Verpaele A, Tonnard P, Matton G. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap. Plast Reconstr Surg 2001;107:719-25.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Fournier gangreninde 80 hastalık tecrübemiz ve bir etiyopatogenez nedeni olarak “travma” Dr. Teoman Eskitaşcıoğlu, Dr. İrfan Özyazgan, Dr. Atilla Coruh, Dr. Galip K Günay, Dr. Mehmet Altıparmak, Dr. Yalcin Yontar, Fatih Doğan† Erciyes Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Kayseri †Şimdiki kurumu: Adıyaman Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Adıyaman

AMAÇ: Bu çalışmanın amacı Fournier gangrenli hastaların bilgilerini geriye dönük olarak analiz etmek ve bunları literatürle karşılaştırarak travmanın bir etiyopatogenez faktörü olarak rolünü araştırmaktır. GEREÇ VE YÖNTEM: Bölümüzde konsülte edilen 126 Fournier gangrenli hastaların bilgileri geriye dönük olarak analiz edildi. BULGULAR: Fournier gangrenli 80 hastanın 76’sı erkek, dördü kadın idi. Hastaların ortalama yaşları 53.5±13.6 idi. Hastalardaki en sık başvuru nedeni şişlik idi (n=74). Hastalardaki en sık etkilenen bölge skrotum idi (n=75). Fournier gangreni için diabetes mellitus predispozan faktör iken travma Fournier gangreni oluşumundan sorumlu olan faktördü. Escherichia coli en sık izole edilen mikroorganizmaydı (n=43, %53.75). Primer kapatım en sık uygulanan teknikdi. Sepsis ve çoklu organ yetersizliği nedeni ile üç hasta hayatın kaybetti. TARTIŞMA: Fournier gangreni halen yüksek mortaliteye sahiptir. Hastalığın hızlı ve doğru teşhisi uygunsuz ve geç tedaviyi ve de hasta mortalitesini önler. Sağlık çalışanlarının perineal bölge travması olan hastalarda Fournier gangreni gelişebileceği hususunda uyanık olmaları gereklidir. Anahtar sözcükler: Fournier gangreni; rekonstrüksiyon; travma. Ulus Travma Acil Cerrahi Derg 2014;20(4):265-274

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ORIGIN A L A R T IC L E

Management of ankle sprains during pregnancy: evaluation of 96 cases Çetin Işık, M.D.,1 Mesut Tahta, M.D.,2 Derya Işık, M.D.,3 Yusuf Üstü, M.D.,4 Mehmet Uğurlu, M.D.,4 Nuray Bozkurt, M.D.,5 Murat Bozkurt, M.D.6 1

Department of Orthopaedics and Traumatology, Ankara Atatürk Training and Research Hospital, Ankara;

Department of Orthopaedic and Trauma Clinic, Igdır State Hospital, Igdır;

Department of Familiy Medicine, Ankara Atatürk Training and Research Hospital, Ankara;

Department of Familiy Medicine, Yıldırım Beyazıt University Faculty of Medicine, Ankara Atatürk Training and Research Hospital, Ankara;

Department of Obstetrics And Gynecology, Gazi University Faculty of Medicine, Ankara;

Department of Orthopaedics and Traumatology, Yıldırım Beyazıt University Faculty of Medicine,

Ankara Atatürk Training and Research Hospital, Ankara

ABSTRACT BACKGROUND: The aim of this study was to suggest a safe management method for the diagnosis and treatment of ankle sprains in pregnant patients. METHODS: Between November 2005 and January 2013, 96 pregnant patients with ankle sprains referred to the department of orthopedics and traumatology were evaluated, retrospectively. The Ottawa ankle rules were used to assess the need for radiologic evaluation. Radiological procedures: Surface USG, X-ray (0,6 mGy, mortise view), MRI (T1 and STIR) and fluoroscopy with 0,8 mGy/s doses 0,4 ms single shot views in surgery room. The results of the operated patients were evaluated with AOFAS scoring system. RESULTS: Forty-four (45,8%) patients were treated with conservative methods and there was no need for radiological evaluation. USG was used in 17 (17,7%), MRI in 24 (25%), X-ray in 4 (4,1%) and both USG and MRI in 7 (7,2%) patients during diagnosis. An algorithm was created for the diagnosis and treatment of pregnant patients with ankle sprains. No complications due to radiological and surgical procedures occurred over pregnancies. The AOFAS score was 83 (65-100) in the operated patients. CONCLUSION: There is no standard management method for the diagnosis and treatment of pregnant patients with ankle sprains. The algorithm presented in this study may be useful. Good results can be obtained with an appropriate preparation and surgical technique. Key words: Ankle; ankle sprains; pregnancy; radiation.

INTRODUCTION Ankle injuries comprise approximately 2.15/1000 of all bodily injuries and are particularly seen in young adults.[1,2] Of these injuries, 174/100,000 result in fractures.[3] The majority of

Address for correspondence: Çetin Işık, M.D. Ankara Atatürk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara, Turkey Tel: +90 312 - 362 96 75 E-mail: ortdrcetin@hotmail.com Qucik Response Code

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sprained ankles are evaluated and treated in the emergency department. The most common injury is an “inversion injury,” when the foot in plantar.[4] Ankle sprains in pregnancy, which require direct radiographs present particular difficulties because of the side-effects of radiation on the fetus. The potential effects of radiation on a growing fetus include prenatal mortality, delayed intrauterine growth, mental retardation, organ malformation, and the development of cancer in childhood.[5] Physicians facing these risks generally avoid the taking of radiographs and may make errors resulting in serious disabilities as ultrasonography (USG) and magnetic resonance imaging (MRI) are not of sufficient benefit. Moreover in literature, there is no detailed information and standardization of the path to follow in such situations. 275

Işık et al. The management of sprained ankles during pregnancy

This study aimed to show a safe and standard route to reaching diagnosis in pregnant patients with a sprained ankle and to evaluate the results of the treatment applied to patients requiring surgical treatment.

MATERIALS AND METHODS A retrospective evaluation was made of 96 pregnant patients who presented at the emergency Department of Ankara Dışkapı Yıldırım Beyazıt Training and Research Hospital with the complaint of a sprained ankle and underwent consultation in the Orthopedic and Traumatology Clinic between November 2005 and January 2013. Number of patients who felt no need for consultation and treatment could not be determined due to defects of archiving system of emergency department. Thirteen patients were excluded from the study if direct radiographs or any other imaging had been taken before consultation with the orthopedic and traumatology clinic. The mean age of the patients was 28 years (range: 21-36 years). Seventeen of the patients were in the first trimester of pregnancy, 46 were in the second trimester and 33 were in the third trimester. The complaints and history of trauma of all the patients were recorded. In the physical examination, the points of pain were determined and syndesmosis injury and instability were evaluated. The need for any imaging method to be applied was determined using the Ottawa ankle criteria (OAC). MRI was applied to patients with deformity, abnormal movement, crepitation or certain indications of fracture such as palpation of fracture (Fig. 1). To determine a fracture on MRI, only T1 and short TI inversion recovery sequences were taken. As the effect of MRI on pregnancy is unknown, patients in the first trimester were dressed in a lead apron and a mortise anterior-posterior direct radiograph was taken of the ankle

Figure 2. Ultrasonography image of lateral malleolar fracture.

only in 15° internal rotation at a dosage of maximum 0.6 mGy, rather than the application of MRI. For patients without definite fracture indications, but who required radiological evaluation as a result of the physical examination, superficial USG was firstly applied (Fig. 2). With USG, the bone cortex discontinuity and superficial ligaments such as the deltoid ligament and the anterior talofibular ligament were evaluated. Then patients were physically examined again. At this stage, MRI was applied additional to the USG in patients where it was seen to be necessary. There was not felt to be any need for computerized tomography for any patient. All the patients determined with a fracture were classified according to the Lauge–Hansen Classification and the mechanism of trauma was recorded. Of these patients, those with appropriate indications for surgical treatment were admitted for surgery in the shortest possible time. The algorithm followed for diagnosis and treatment is given schematically in Fig. 3. Spinal anesthesia was preferred for all patients. All patients were dressed in a lead apron before staining and draping (Fig. 4). Preoperative 1 g cephalosporin prophylaxis and 1 g 2x1/24 hours postoperative antibiotic treatment was applied to all patients. Fluoroscopy was only used when necessary during surgery at a dose of 0.8 mGy/s in single applications of 0.4 ms, a maximum of twice on the same patient. Mechanical and pharmacological prophylaxis for deep venous thrombosis was applied and early mobilization was provided for all patients. Following surgery, the patients were followed up in respect of the outcome of the pregnancy and surgical results. At the final follow up examination, the ankles of the patients who underwent surgery were evaluated with the American Orthopedic Foot and Ankle Society (AOFAS) score.

RESULTS Figure 1. Fracture clearly shown on T1 magnetic resonance imaging sequences.

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Of the 96 patients evaluated with the complaints of sprained ankle, 44 (45.8%) were not felt to be in need of any imaging method and were treated conservatively (cold compress, elUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Işık et al. The management of sprained ankles during pregnancy

Patient Complaint Experienced Trauma Phsical Examination (EFF and OAR)

EFF (–)

EFF (+)

EFF (–)

OAR (–)

Pain Edema Hematoma Ecchymosis

(–)

Pain Edema Hematoma Ecchymosis

OAR (+)

(+)

MRI X-ray (Trimester 1)

Surface USG

Physical Examination

Displaced Fracture (+)

Nondisplaced Fracture (–) Fracture (+) Lig. Lesion (–) Lig. Lesion (+) If Needed

MRI X-ray (Trimester 1) Nonoperative Treatment Follow

Nonoperative Treatment

Surgery Or Nonoperative Treatment

Figure 3. Schematic representation of the diagnostic and treatment algorithm that was followed.

evation, bandage, rest, medical treatment). All patients were recommended to follow polyclinic visits. However, there were 15 patients who couldn’t be reached or didn’t come to visits. Of the other 52 patients, MRI was applied to 24 of 28 patients with definite fracture indications and for four patients in the first trimester, a lead apron was worn and a mortise radiograph of the ankle only was taken at a low dose. After physical examination, 24 patients who did not have definite indications of fracture, but required a direct radiograph according to the OAC were firstly evaluated with superficial USG. In 17 patients (17.7%), the USG images were seen to be sufficient. While no bone pathology was determined in 11 (11.4%) of these patients, in 5 (5.2%) below the level of syndesmosis in the lateral malleolus and in one patient in the medial malleolus, a 1 mm discontinuation of the cortex was determined, which was evaluated as non-displaced fracture. A short-leg circular plaster cast was applied to patient determined with Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

bone pathology and a short-leg plaster splint was applied to the others. In two patients with no bone pathology, MRI was required during follow up and they were treated conservatively. In the remaining seven patients, MRI was required additional to USG (Table 1). In the 35 (36.4%) patients to whom MRI and direct radiographs were applied, there was an isolated malleolar fracture

Figure 4. A lead apron was worn preoperatively by all pregnant patients.

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Table 1. The distribution of patients according to the need for radiological examination

Total

Radiological examination (−)

Radiological examination (+)

Number of patients

44 (%45.8)

52 (%54.2)

USG 17

MRI 24

X-ray 4

USG+MRI

(%17.7)

(%25)

(%4.1)

7 (%7.2)

USG: Ultrasonography; MRI: Magnetic resonance imaging.

Table 2. The distribution of patients according to the treatment protocol

EFF (−) EFF (+) OAR (−) (number of patients) (number of patients)

EFF (−) OAR (+) (number of patients)

Total

44 28 24

X-ray

–

Ultrasonography – – 24 Magnetic resonance imaging

–

Conservative treatment 44 7 18 Surgical treatment – 21 6 EFF: Exact fracture findings; OAR: Ottawa ankle rules.

in 21 below, above or at the syndesmosis level. Bimalleolar fractures were determined in nine patients and trimalleolar in five patients. In the treatment of eight of the 14 patients with a fracture at the level of syndesmosis, the syndesmosis was seen to be healthy and a short-leg circular plaster cast was applied. The remaining 27 (28.1%) patients were prepared for surgery (Table 2). Supination+adduction injuries were present in 13 patients, supination+external rotation in eight and pronation+external rotation in six. Four of the patients were in the first trimester, 15 in the second trimester and eight in the third trimester. Spinal anesthesia was preferred for all patients. Staining and draping procedures were made with the patient wearing a lead apron. Fluoroscopy was not used at all in five of the six patients with a lateral malleolar fracture and it was not necessary to be used more than twice in the remaining patients. For all the patients, the utmost care was taken in the decision as to whether fluoroscopy was necessary. Postoperatively, there was no necessity to terminate any of the pregnancies. In the follow up no complications in the pregnancies were encountered which could have arisen from the surgical treatment. At the final examination, the mean AOFAS score of all patients was 83 (range, 65-100); the mean AOFAS score was 88 (range, 70-100) in those with a single malleolar fracture; 81 (range, 65-100) in those with a bimalleolar fracture, and 79 (range, 65-95) in those with a trimalleolar fracture. 278

DISCUSSION We think that the algorithm, we defined is going to fill an important space about the management of sprained ankles during pregnancy. The most important specification of this algorithm is to provide protection for pregnant patients from radiation in all steps. In addition, the results show that this algorithm is an easy-applicable way of treating patients. The majority of sprained ankles can be successfully treated in the emergency department. When diagnosis cannot be clearly made, when there is indecision as to the need for imaging techniques, and when there are definite indications of a fracture, an Orthopedic and Traumatology specialist should be consulted to make an accurate diagnosis and define the correct approach for treatment. Physical examination is extremely important in the approach to sprained ankles. This is even more important in situations where there is a risk in taking direct radiographs, such as in pregnancy. With the application of the OAC, exposure to radiation is significantly reduced without compromising diagnostic thoroughness, time is saved and healthcare costs are reduced.[6,7] In a study by Jenkin et al.,[8] OAC sensitivity was reported to be 98%. In the current study, there was no problem about 29 patients whose OAC (−) and who wasn’t felt to be any need for any imaging study. However, because of 15 “lost” patients with OAC (−), an exact percentage couldn’t be given. It was considered necessary to apply the OAC to the ankle sprains Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Işık et al. The management of sprained ankles during pregnancy

of pregnant patients. As seen in this study, the treatment of 45.8% of the patients was made without the application of direct radiographs to those who might be affected teratogenically and without MRI in the first trimester for which the effects are not clearly known. For those who required radiological evaluation, a graduated approach was preferred. Thus, diagnosis was made in 17.7% of cases from superficial USG only, without direct radiographs or MRI. While the effect of MRI in the first trimester is not clear, pregnant patients are exposed to radiation with direct radiographs. The dose of radiation exposed to is important. In a study by McCollough et al.,[9] no malformation was reported in 95.8% of fetuses from a dose of 100 mGy radiation and no childhood cancer developed in 99.7% and it was emphasized that doses below 50 mGy can be disregarded. In the same study, it was stated that there was a minimal effect on the fetus of radiation focused on the abdomen and pelvis as the dose reaching the fetus in radiography, fluoroscopy, and tomography in these regions rarely exceeds 25 mGy. In the current study, a maximum dose of 0.6 mGy was used for the ankle anterior-posterior radiographs. In addition, all patients wore a lead apron to achieve the minimum effect from radiation to the embryo or fetus. In patients undergoing surgery, fluoroscopy was only used at a dose of 0.8 mGy and 0.4 ms single image twice at the most, in cases thought to be at risk of the screw penetrating the joint in the reduction of the fracture line. For all the patients to be minimally affected, a lead apron was worn before the operation started. The treatment choices for sprained ankles differ according to the form and nature of the injury. Conservative treatment can be selected for injuries with no accompanying fracture, when the syndesmosis integrity is not impaired, for non-displaced stable fractures and for displaced fractures where stable anatomic reduction of the ankle mortise can be achieved.[10] Surgical treatment is preferred for fractures where reduction cannot be achieved or sustained, where there is talus displacement and expansion in the ankle mortise and where reduction can only be achieved with the foot in an abnormal position.[11] Surgical indications do not change in pregnancy so the surgical indications cannot be avoided. Persistence in conservative treatment of fractures which require surgery can have catastrophic results. In the current study, the mean AOFAS score of the patients who underwent surgery was evaluated as 83 (good). With Lauge-Hansen supination-adduction injury, the AOFAS score mean was 90 (70-100); with supination-external rotation and pronation-external rotation injury the AOFAS score was 79 (65-100). The reason for the high rate of patients undergoing surgical treatment in the current study (28/96 cases, 29.1%) may be that the majority of cases

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treated conservatively or who were not felt to need treatment were evaluated in the emergency department without being sent to the Orthopedic and Traumatology Department for consultation. The current study would be more valuable if there was more study in the literature. Studies with wide numbers of patients will be useful. That there is no standardization in the literature for an approach to sprained ankles in pregnant patients leaves physicians in a difficult situation. The current study can be of use in respect of the graduated approach, which was applied and the diagnosis and treatment algorithm defined herein. The indications for surgical treatment of a sprained ankle do not change in pregnancy and good results can be obtained with surgery and careful preparation. Conflict of interest: None declared.

REFERENCES 1. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am 2010;92:2279-84. 2. Tiemstra JD. Update on acute ankle sprains. Am Fam Physician 2012;85:1170-6. 3. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 2002;31:430-3. 4. Struijs PA, Kerkhoffs GM. Ankle sprain. Clin Evid (Online) 2010;05:1115. 5. Wagner LK, Lester RG, Saldana LR. Exposure of the pregnant patient to diagnostic radiations: a guide to medical management. Madison, Wis: Medical Physics Publishing; 1997. 6. Aginaga Badiola JR, Ventura Huarte I, Tejera Torroja E, Huarte Sanz I, Cuende Garcés A, Gómez Garcerán M, et al. Validation of the Ottawa ankle rules for the efficient utilization of radiographies in acute lesions of the ankle. [Article in Spanish] Aten Primaria 1999;24:203-8. [Abstract] 7. Dowdall H, Gee M, Brison RJ, Pickett W. Utilization of radiographs for the diagnosis of ankle fractures in Kingston, Ontario, Canada. Acad Emerg Med 2011;18:555-8. 8. Jenkin M, Sitler MR, Kelly JD. Clinical usefulness of the Ottawa Ankle Rules for detecting fractures of the ankle and midfoot. J Athl Train 2010;45:480-2. 9. McCollough CH, Schueler BA, Atwell TD, Braun NN, Regner DM, Brown DL, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics 2007;27:909-18. 10. Dietrich A, Lill H, Engel T, Schönfelder M, Josten C. Conservative functional treatment of ankle fractures. Arch Orthop Trauma Surg 2002;122:165-8. 11. Michelson JD. Fractures about the ankle. J Bone Joint Surg Am 1995;77:142-52.

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KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Gebelikte ayak bileği burkulmalarına yaklaşım ve tedavi: 96 olgunun değerlendirilmesi Dr. Çetin Işık,1 Dr. Mesut Tahta,2 Dr. Derya Işık,3 Dr. Yusuf Üstü,4 Dr. Mehmet Uğurlu,4 Dr. Nuray Bozkurt,5 Dr. Murat Bozkurt6 Ankara Atatürk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara; Iğdır Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Iğdır; Ankara Atatürk Eğitim ve Araştırma Hastanesi, Aile Hekimliği Kliniği, Ankara; 4 Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Ankara Atatürk Eğitim ve Araştırma Hastanesi, Aile Hekimliği Kliniği, Ankara; 5 Gazi Üniversitesi Tıp Fakültesi, Kadın Hastalıkları ve Doğum Anabilim Dalı, Ankara; 6 Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Ankara Atatürk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara 1 2 3

AMAÇ: Bu çalışmada ayak bileği burkulması olan gebelerde tanıya ulaşmada ve tedavide güvenli, standart bir yol göstermeyi ve uyguladığımız cerrahi tedavinin sonuçlarını değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Kasım 2005-Ocak 2013 tarihleri arasında ayak bileği burkulması şikayeti ile başvurup Ortopedi ve Travmatoloji Kliniği’ne konsülte edilen 96 gebe geriye dönük olarak değerlendirildi. Ottawa Ayak Bileği Kriterleri (OABK) kullanılarak hastalarda görüntüleme yöntemi gereği olup olmadığı belirlendi. Radyolojik inceleme olarak yüzeyel USG, direkt grafi (0.6 mGy’yi geçmeyecek dozda sadece Mortis grafisi), MRG (sadece T1 ve STIR) ve ameliyathanede 0.8 mGy/s dozunda, 0.4 ms’lik tek çekimler şeklinde floroskopi kullanıldı. Cerrahi tedavi uygulanan hastalar gebeliklerinin akıbeti, cerrahinin sonuçları ve AOFAS skoru ile değerlendirildi. BULGULAR: Doksan altı hastanın 44’ü (%45.8) bir görüntüleme yöntemine başvurma gereği duyulmadan konservatif yöntemlerle tedavi edildi. Geri kalan 52 hastanın 17’sinde (%17.7) USG, 24’ünde (%25) MRG, dördünde (%4.1) direkt grafi ve yedisinde (%7.2) USG+MRG ile tanıya ulaşıldı. Bu tür hastalarda izlenebilecek bir tanı ve tedavi algoritması oluşturuldu. Ameliyat sonrası hastaların hiçbirinde gebeliğin sonlandırılması gereği duyulmadı ve cerrahi tedavinin gebelikleri üzerinde yol açtığı bir komplikasyona rastlanmadı. Cerrahi tedavi uygulanan hastaların ortalama AOFAS Skoru 83 (65-100) bulundu. TARTIŞMA: Gebelikte ayak bileği burkulmalarına yaklaşımda literatürde standardizasyon yoktur. Çalışmamızda uyguladığımız tanı ve tedavi algoritması bu açıdan faydalı olabilir. Cerrahi tedavide, dikkatli hazırlık ve teknik ile iyi sonuçlar alınmaktadır. Anahtar sözcükler: Ayak bileği; ayak bileği yaralanmaları; gebelik; radyasyon. Ulus Travma Acil Cerrahi Derg 2014;20(4):275-280

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doi: 10.5505/tjtes.2014.94914

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ORIGIN A L A R T IC L E

Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients: 14 years of experience in a burn unit Yalcin Yontar, M.D.,1 Aliye Esmaoglu, M.D.,2 Atilla Coruh, M.D.1 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Erciyes University Faculty of Medicine, Kayseri;

Department of Anesthesia and Intensive Care, Erciyes University Faculty of Medicine, Kayseri

ABSTRACT BACKGROUND: The aim of this study was to investigate the hot milk burns among the pediatric patients and to compare our experiences with similar studies in the literature. METHODS: A 14-year retrospective study was conducted on 159 pediatric patients with hot milk burn who hospitalized at the Burn Unit of Erciyes University Medical Faculty. RESULTS: There were 81 male and 78 female patients with a male to female ratio of 1.03:1. The mean age of the patients was 2.7±1.6 years. The initial injury was immersion in 59.7% of the patients and spillage in 40.3%. The mean burned body surface area of the patients was 18.6±10.8%. Twenty-two percent of the patients had moderate, and 78% had major burn trauma. Forty-nine percent of the patients received burn wound debridement and reconstruction with auto-skin grafts. Our burn unit’s mortality rate was 1.5% among 542 pediatric patients with hot water, and 5.6% among 159 pediatric patients with hot milk burn during the same period, respectively. CONCLUSION: Hot milk burns should be considered as separately from other hot liquid burns which do not contain fat such as water, tea, and coffee. Physical and chemical properties of milk because of its high content of fat give rise to more tissue destruction, increased morbidity and mortality. Key words: Hot milk burn; pediatric burn; scalding.

INTRODUCTION Burn trauma has been one of the most devastating health problems for all the times. It requires a treatment process including a multidisciplinary approach by experienced burn surgeons and health care professionals in a well-equipped burn unit or center. Majority of burns among the pediatric patients was caused by scalding in both developed[1,2] and developing countries,[3,4] as well as in Turkey.[5-7] Particularly, this trauma is frequently observed among the children that belonged to Address for correspondence: Yalcin Yontar, M.D. Erciyes Üniversitesi Tıp Fakültesi, Gevher Nesibe Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Kat: 6, Melikgazi, 38039 Kayseri, Turkey Tel: +90 352 - 207 66 66 / 20655 E-mail: dr.yyontar@gmail.com Qucik Response Code

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the preschool period.[1-7] The region that our burn unit provided health care has some traditional sources of burn trauma including homemade tomato paste, jam, boiled grape juice, and dairy products such as cheese and yogurt.[5,8] Burns due to hot milk should be considered as separately because of its physical and chemical properties. There are limited data and studies about this causative agent in the literature. The aim of this study was to investigate hot milk burns among the pediatric aged patients and to compare our data with the literature.

MATERIALS AND METHODS A 14-year retrospective study was conducted on 159 pediatric patients with hot milk burns who hospitalized at the Burn Unit of Erciyes University Medical Faculty between January 2000 and November 2013. According to the “American Burn Association’s Grading System for Burn Severity and Disposition of Patients,” the study population comprised moderate burn injuries with burned body surface area (BSA) between 5% and 10% and major burn injuries with burned BSA >10% or any significant burn to the head and neck, genitalia or major 281

Yontar et al. Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients

RESULTS There were 81 male and 78 female patients with a male to female ratio of 1.03:1. The age of the patients was ranged from 2 months to 10 years and the mean age was 2.7±1.6 years. One hundred and fifty-five patients were under 6 years of age. The greatest number of injuries was observed in patients who were 2-3 years of age (n=53) (Fig. 1). The majority of patients were admitted from rural regions (n=127). Immersion burns were observed in 59.7% (n=95) of 60

Male Female

Site of injury

n %

Trunk

127 79.8

Lower extremities

121

76.1

Upper extremities

40.2

Head and neck

21.3

Genito-perineal region

4.4

These numbers add to more than 159 because some patients had more than one affected area.

the patients due to mostly falling into a large cauldron made of thinned copper inside of which is tin-coated to preserve much heat. Furthermore, 40.3% of the patients (n=64) were scalded by spillage. The mean burned BSA of patients was 18.6±10.8% (range, 3-54%). Forty-four percent of the patients (n=71) received injuries in the range of 11-20% burned BSA. Only eight patients had burned BSA over 40% (Fig. 2). The trunk (n=127) and lower extremities (n=121) were affected most commonly (Table 1). Twenty-two percent of the patients (n=35) had moderate, and 78% (n=124) had major burn trauma. Mean ABSI score of the patients was 3.7±1.2 (range, 1-7). Five patients were epileptics, one patient had congenital 60 50 40 30 20 10

ay M

Months

Figure 3. Monthly distribution of burn admissions.

10 0

No. of patients

Table 1. Affected anatomic sites of 159 patients

No. of patients

joints.[9] Outpatients with minor burns were excluded from the study group. The severity of burn injury was assessed by “abbreviated burn severity index (ABSI)” score.[10] Initial fluid resuscitation of patients was calculated by the Parkland formula to maintain hemodynamic stability and adequate urine output. When indicated, anti-biotherapy was initiated by the pediatric infectious disease specialist and modified according to the results of antibiotic susceptibility tests. Systemic prophylactic antibiotics were not used routinely except in the perioperative period of surgical procedures. Early excision of the burn wound and closure with auto-skin grafts were applied to all deep partial and full-thickness burns. Intermingled allo- and auto-skin grafts[11] were applied to extensive (>20%) deep partial and full-thickness burns due to limited donor site for auto-skin graft harvesting. Wound dressing was applied with antibiotic impregnated sterile Vaseline gauze to superficial burns for primary epithelization. Collected demographic data of patients were analyzed statistically by “Statistical Package for the Social Sciences” (version 17.0.0, SPSS Inc., Chicago, IL, USA).

0-1

1-2

2-3

3-4 Age

4-5

5-6

Figure 1. Patients’ distribution according to age and sex.

3.8% Autoskin graft and alloskin graft

No. of patients

100 47.1% Primary epithelization with wound dressing

80 60 40 20 0

0-10

11-20

21-30 Burned BSA

31-40

Figure 2. Patients’ distribution according to burned BSA.

282

49.1% Autoskin graft

>40

Figure 4. Patients’ distribution according to applied therapy.

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Yontar et al. Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients

Table 2. List of most important risk factors for scalding injury in children[1-3,5-7,17-19,22-24]

(a)

Being male Preschool period Young parents Educational status of the parents Living in rural areas Low socioeconomic level Malnutrition Psychiatric alterations

(b)

Physical defects Chronic illnesses Heating of hot milk in large cauldrons Cultural and ethnic factors Affected body surface area Deep dermal injury

heart disease, one patient had iron deficiency anemia, and one patient had asthma. The highest incidence of burn admissions were in July (n=31) and August (n=23) (Fig. 3). Forty-seven percent (n=75) of the patients received only burn wound dressing for primary epithelization. Forty-nine percent of the patients (n=78) received burn wound debridement and reconstruction with auto-skin grafts. Intermingled allo- and auto-skin grafts were applied in 6 patients (Fig. 4). The mean time between the injury and the surgery was 8.3±4.3 days. Mean hospital stay was 15.4±9.8 days. Nine patients exhibited a mortal course due to hypovolemic shock during initial fluid resuscitation period (n=3) and burn wound sepsis (n=6) with a mortality rate of 5.6%.

DISCUSSION Different physical and chemical properties of the hot liquids such as boiling temperature, viscosity and heat capacity play an important role regarding the degree of tissue damage.[12]

Figure 5. (a) Boiled mik in a large cauldron on wood fire, closed to the ground. (b) A cauldron that used for boiling milk is large enough to fit a preschool-aged child.

Heat is defined as the form of energy that is transferred between two systems or a system and its surroundings due to the presence of a temperature difference. The heat is always transferred from high to low temperatures until the temperature equality was established.[13] The amount of heat required to increase the temperature of any material is given by the equation of Q=mCΔT; where Q is the heat (Joule), ΔT the change in temperature (°C), m the mass (g), and C the heat capacity (Joule/g°C). Heat capacity is defined as the energy required to raise the temperature of unit mass of a material by 1°C.[14] According to this equation, the tissue destruction and the severity of the burn injury with a high heat capacity liquids is worse than the lower ones, which has the same mass

Table 3. Data of patients with hot milk burn injury from different articles

Number of patients

Mean burned BSA (%)

Haberal et al.[28] 69

Mortality rate (%)

–

61.7

Tarim et al.[15] 45 33.5 33.3 Yasti et al.[29] 81 25.3 32.1 Türegün et al.[25] 15

Aliosmanoglu et al. 82

16.2

1.2

Our study

18.6

5.6

[17]

159

BSA: Body surface area.

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Yontar et al. Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients

and the temperature. The heat capacity and the boiling points of fat and fat included liquids are higher. In addition, viscosity that gained by the fat component provides prolonged contact with the surfaces. All of these factors provide more heat transmission to the tissues and thus, more tissue destruction, higher morbidity and mortality for fat and fat included liquids. Our burn unit’s mortality rate of 1.5% among 542 pediatric patients with hot water burn and 5.6% among 159 pediatric patients with hot milk burn support all of these explanations. Noted risk factors which contribute to the incidence, prevalence, morbidity, and mortality of burn injury among children are listed in Table 2. Families with a large number of children, and environmental factors are associated with the increased risk of accidental injury in childhood.[15] In rural Kayseri, much like other rural regions of Turkey, families come from low social status and economic income. They generally produce dairy products by their own means. The first-step for the production process of dairy products involves boiling milk in a large cauldron, which is large enough to fit a preschool child, placed close to the ground in the backyard, and without a lid on a wood fire (Figs. 5a and b). In such an over-crowded family and an unsupervised environment, it is more difficult for a parent to keep track of the child’s activities and to be ready and available to act for protecting them from accidental injuries. To be less able to perceive danger, have less control over their environment and to react slower in situations that can lead to injury, occasionally make the injury unavoidable in small children.[16] As shown in our study, childhood scalding injury is frequently observed among the preschool period, especially between the ages of 2 and 3 years[1-3,5-7,17-19] in which the abilities that increased tendency to injuries were gained such as independent mobility, exploratory behavior, and hand-to-mouth activity.[20,21] Similar to the previous studies from Turkey[23,25] the mechanism of hot milk burns was most commonly the immersion and most frequently affected anatomical parts were the lower extremities and the trunk. Male predominance was demonstrated in our study that in agreement with the previous studies, which had a male to female ratio ranged between 0.9:1 and 2:1.[15-17,25] The reason for the high incidence of hot milk burns in summer season is the increased production of cheese and yogurt in this period (Fig. 3). Fifty-one percent of our patients (n=81) required burn wound debridement and reconstruction with auto-skin with/ without allo-skin grafts. The significant finding was that the mortality rate of the patients decreased after 2002, in which we started to perform intermingled auto- and allo-skin grafts in hot milk burns with burned BSA >20%. The mortality rate was 15.1% before 2002 and 3.1% after 2002 with an overall mortality rate of 5.6%. The practice of early burn wound excision and temporary or permanent closure of the burn wound is the standard therapy 284

in burns, which has further reduced the mortality rate of severe burns and improves chances of survival by decreasing the stimulus of overwhelming systemic inflammatory response, preventing infectious, and metabolic complications.[26,27] The mortality rate of hot milk burns was 61.7% in the study of Haberal et al.[28] In their publication, there was no data of patients with hot milk burns regarding age, burned BSA, accompanying trauma, or diseases, which could explain their high mortality rate. Early excision with closure and coverage techniques that we applied to all deep partial-thickness and full-thickness burns may explain the lower mortality rate of our study compared to the previously reported mortality rates.[15,25,28,29] Another explanation of the lower mortality rate of our study may be the lower mean burned BSA when compared to the previous studies.[15,25,29] Furthermore, the mortality rate and mean burned BSA of patients were the lowest in the report of Aliosmanoglu et al.[17] (Table 3).

Conclusion Hot milk burns should be considered as separately from other hot liquid burns, which do not contain fat such as water, tea, and coffee. Physical and chemical properties of milk because of its high content of fat give rise to more tissue destruction, increased morbidity and mortality. Hence, hot milk burn patient should be evaluated initially by skilled burn surgeons for the management of hot milk burn treatment. Conflict of interest: None declared.

REFERENCES 1. Light TD, Latenser BA, Heinle JA, Stolpen MS, Quinn KA, Ravindran V, et al. Demographics of pediatric burns in Vellore, India. J Burn Care Res 2009;30:50-4. 2. Abeyasundara SL, Rajan V, Lam L, Harvey JG, Holland AJ. The changing pattern of pediatric burns. J Burn Care Res 2011;32:178-84. 3. Cuenca-Pardo J1, de Jesús Alvarez-Díaz C, Comprés-Pichardo TA. Related factors in burn children. Epidemiological study of the burn unit at the “Magdalena de las Salinas” Traumatology Hospital. J Burn Care Res 2008;29:468-74. 4. El-Badawy A, Mabrouk AR. Epidemiology of childhood burns in the burn unit of Ain Shams University in Cairo, Egypt. Burns 1998;24:72832. 5. Coruh A, Gunay GK, Esmaoglu A. A seven-year burn unit experience in Kayseri, Turkey: 1996 to 2002. J Burn Care Rehabil 2005;26:79-84. 6. Sakallioğlu AE, Başaran O, Tarim A, Türk E, Kut A, Haberal M. Burns in Turkish children and adolescents: nine years of experience. Burns 2007;33:46-51. 7. Anlatici R, Ozerdem OR, Dalay C, Kesiktaş E, Acartürk S, Seydaoğlu G. A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and mortality. Burns 2002;28:239-43. 8. Coruh A, Dogan F, Gunay GK. An undescribed scalding, “cökelek” burns in Turkish children: is acidic effect the reason of high mortality and double-hit injury? J Burn Care Res 2007;28:861-4. 9. Hospital and prehospital resources for optimal care of patients with burn injury: guidelines for development and operation of burn centers. Ameri-

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Yontar et al. Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients can Burn Association. J Burn Care Rehabil 1990;11:98-104. 10. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med 1982;11:260-2. 11. Coruh A, Tosun Z, Ozbebit U. Close relative intermingled skin allograft and autograft use in the treatment of major burns in adults and children. J Burn Care Rehabil 2005;26:471-7. 12. Allen SR, Kagan RJ. Grease fryers: a significant danger to children. J Burn Care Rehabil 2004;25:456-60. 13. Cengel YA, Michael AB. Energy, energy transfer, and general energy analysis. In: Thermodynamics: an engineering approach. 7th ed. New York: McGraw-Hill; 2011. p. 60. 14. Liua X, Nacsonb S, Grigorievb A, Lyndsb P, Pawliszyna J. A new thermal desorption solid-phase microextraction system for hand-held ion mobility spectrometry. Anal Chim Acta 2006;559:159-65. 15. Tarim A, Nursal TZ, Basaran O, Yildirim S, Türk E, Moray G, et al. Scalding in Turkish children: comparison of burns caused by hot water and hot milk. Burns 2006;32:473-6. 16. Cekin N, Akçan R, Arslan MM, Hilal A, Eren A. An unusual cause of death at preschool age: scalding by hot milk. Am J Forensic Med Pathol 2010;31:69-71. 17. Aliosmanoglu I, Aliosmanoglu C, Gul M, Arikanoglu Z, Taskesen F, Kapan M, et al. The comparison of the effects of hot milk and hot water scald burns and factors effective for morbidity and mortality in preschool children. Eur J Trauma Emerg Surg 2013;39:173-6. 18. Werneck GL, Reichenheim ME. Paediatric burns and associated risk factors in Rio de Janeiro, Brazil. Burns 1997;23:478-83. 19. Henderson P, Mc Conville H, Höhlriegel N, Fraser JF, Kimble RM. Flammable liquid burns in children. Burns 2003;29:349-52. 20. Barrow RE, Spies M, Barrow LN, Herndon DN. Influence of demo-

graphics and inhalation injury on burn mortality in children. Burns 2004;30:72-7. 21. Mytton JA, Towner EM, Kendrick D, Stewart-Brown S, Emond A, Ingram J, et al. The First-aid Advice and Safety Training (FAST) parents programme for the prevention of unintentional injuries in preschool children: a protocol. Inj Prev 2014 ;20:e2. 22. Celko AM, Grivna M, Dánová J, Barss P. Severe childhood burns in the Czech Republic: risk factors and prevention. Bull World Health Organ 2009;87:374-81. 23. Türegün M, Celiköz B, Nişanci M, Selmanpakoğlu N. An extraordinary cause of scalding injury in childhood. Burns 1997;23:170-3. 24. Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics 2003;111:e683-92. 25. Flavin MP, Dostaler SM, Simpson K, Brison RJ, Pickett W. Stages of development and injury patterns in the early years: a population-based analysis. BMC Public Health 2006;6:187. 26. Alp E, Coruh A, Gunay GK, Yontar Y, Doganay M. Risk factors for nosocomial infection and mortality in burn patients: 10 years of experience at a university hospital. J Burn Care Res 2012;33:379-85. 27. Coruh A, Yontar Y. Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting. J Burn Care Res 2012;33:e94-e100. 28. Haberal M, Ugar N, Bayraktar U, Ener Z. Analysis of 1005 burn patients treated in our centre. Ann Medit. Burns Club 1993;6:73-5. 29. Yastı AÇ, Koç O, Şenel E, Kabalak AA. Hot milk burns in children: a crucial issue among 764 scaldings. Ulus Travma Acil Cerrahi Derg 2011;17:419-22.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Yüz elli dokuz pediyatrik hastada sıcak süt nedeniyle görülen yanık travmasının geriye dönük analizi: Bir yanık ünitesindeki 14 yıllık deneyim Dr. Yalcin Yontar,1 Dr. Aliye Esmaoglu,2 Dr. Atilla Coruh1 1 2

Erciyes Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Kayseri Erciyes Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Kayseri

AMAÇ: Bu çalışmada, pediyatrik hastalarda gözlenen sıcak süt yanıklarının incelenmesi ve elde edilen verilerin literatürle karşılaştırılması amaçlandı. GEREÇ VE YÖNTEM: Erciyes Üniversitesi Tıp Fakültesi Yanık Ünitesi’nde hastaneye yatırılmış 159 pediyatrik hasta üzerinde 14 yıllık geriye dönük bir çalışma yapıldı. BULGULAR: Hastaların 81’i erkek ve 79’u kız olup erkek: kız oranı 1.03:1 idi. Hastaların yaş ortalaması 2.7±1.6’ydı. Hastaların %59.7’si imersiyon, %40.3’ü ise sütün üzerine dökülmesi/sıçraması sonucu yaralanmıştı. Hastaların ortalama yanık yüzey alanı %18.6±10.8’di. Hastaların %22’sinde orta derecede yanık travması varken; %78’inde ciddi yanık travması mevcuttu. Hastaların %49’unun tedavisi debridman ve otoderi grefti ile gerçekleştirildi. Yanık ünitemizde aynı dönem içerisinde hastaneye yatırılmış 542 sıcak su yanıklı hastanın mortalite oranı %1.5 iken, 159 sıcak süt yanıklı hastanın mortalite oranı ise %5.6’ydı. TARTIŞMA: Sıcak süt yanıklarının su, kahve ve çay gibi içeriğinde yağ olmayan sıcak sıvılar nedeniyle meydana gelen yanıklarından ayrı olarak değerlendirilmesi gerekmektedir. Sütün sahip olduğu yüksek yağ içeriği nedeniyle kazanmış olduğu fiziksel ve kimyasal özellikler dokularda daha fazla tahribata neden olmakta ve bu nedenle mortalite ve morbidite oranları daha fazla olmaktadır. Anahtar sözcükler: Haşlanma; pediyatrik yanıklar; sıcak süt yanıkları. Ulus Travma Acil Cerrahi Derg 2014;20(4):281-285

doi: 10.5505/tjtes.2014.41027

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K Lİ NİK Ç A LI ŞM A

Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları Dr. Turgut Akgül,1 Dr. Sinan Zehir,2 Dr. Güzelali Özdemir,3 Dr. Ferit Yücel,5 Dr. Abdulkadir Türk,4 Dr. Özgür Çiçekli4 1

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul;

Hitit Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Çorum;

Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul;

Şanlıurfa Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Şanlıurfa

Özel Edesa Hastanesi, Şanlıurfa

ÖZET AMAÇ: Klavikula kırıklarının tedavisinde kabul gören yaklaşım konservatif yöntemler olmakla beraber deplase ve parçalı kırıklarda cerrahi tedavi önerilmektedir. Cerrahi tedavide ise açık repozisyon ve plak vida uygulamaları yaygın olarak kullanılmaktadır. GEREÇ VE YÖNTEM: Çalışmamızda Edinburg tip 2b klavikula diyafiz kırığı olan, açık repozisyon ve anatomik kilitli klavikula plağı ile tedavi edilmiş olan 31 hastanın radyolojik ve klinik sonuçları geriye dönük olarak değerlendirildi. BULGULAR: Çalışmaya alınan 31 hastanın 32 klavikula cisim kırığının 17’si sağ ve 15’i sol taraf idi. Olguların 24’ü erkek, 7’si kadın ve ortalama yaş 28 (15-62) yıl idi. Hastaların ortalama takip süreleri 12.3 (6-36) ay ve kaynama 15.2 (12-20) hafta idi. Tip 2 b2 kırığı olan hastalardan üç tanesinde kaynama süresi 12 haftadan uzun idi. Hastaların kaynama sonrasındaki Constant skorlaması 92 (85-98) ve DASH değerleri 9 (2-20) olarak belirlendi. 32 klavikula kırığının üçünde (%9) implant bağlı sorun belirlendi. SONUÇ: Klavikula cisim kırıklarının cerrahi tedavisinde anatomik kilitli klavikula plakları ile fonksiyonel ve radyolojik olarak başarılı sonuçlar alınabilmektedir. Anahtar sözcükler: Klavikula diafiz kırığı; kilitli anatomik klavikula plağı.

GİRİŞ Klavikula kırıkları omuz bölgesi kırıklarının %35’ini, tüm erişkin kırıklarının %2.6-%4’ünü oluşturmaktadır.[1-3] Erişkinde 30 yaş altı erkeklerde daha sık karşılaşılmaktadır.[4] Klavikula cisim kırıkları eskiden çoğunlukla konservatif olarak tedavi edilirken,[5-7] yakın zamanlarda konservatif tedavi ile kaynamama riskinin fazla olduğu ve fonksiyonel kayıplara yol açtığı belirtilmiştir.[8-10] Deplase klavikula cisim kırıklarının cerrahi teda-

Sorumlu yazar: Dr. Turgut Akgül, İstanbul Üniversitesi İstanbul Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul Tel: +90 212 - 414 20 00 E-posta: doktorturgut@yahoo.com

286

visinin konservatif tedaviye göre fonksiyonel sonuçları daha çok geliştirdiği de belirtilmiştir.[8-10] Cerrahi tedaviler arasında çeşitli yöntemler belirtilmekle beraber plak ve vida kombinasyonları en sık kullanılan yöntemdir.[8,11] Açık repozisyon ve kompresyon yapan klasik plak uygulamalarında kaynamama, kötü kaynama, enfeksiyon ve plak irritasyonu gibi komplikasyonlar bildirilmiştir.[12-15] Yapılan çalışmalar kırık redüksiyonu ve stabilite sağlamakta DCP (Dinamik kompresyon plakları) ve LC-DCP (kilitli ve dinamik kompresyonlu plak) arasında fark olmadığını göstermekle beraber LC-DCP plaklarının az temas yüzeyleri sayesinde periost dolaşımını bozmadığı ve kırık iyileşmesine pozitif etki ettiği gösterilmiştir.[16-23] Çalışmamızda kilitli anatomik klavikula plakları ile tedavi edilen klavikula kırıklarının radyolojik ve klinik sonuçlarını araştırdık.

Ulus Travma Acil Cerrahi Derg 2014;20(4):286-290 doi: 10.5505/tjtes.2014.88303

GEREÇ VE YÖNTEM

Telif hakkı 2014 TJTES

Kliniğimizin acil servisine Kasım 2009-Kasım 2012 tarihleri arasında klavikula diafiz kırığı tanısı ile başvuran cerrahi Ulus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, Sayı. 4

Akgül ve ark. Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları

tedavi edilen 31 hastanın 32 klavikula cisim kırığı çalışmaya alındı. Çalışmaya alınan 31 hasta geriye dönük olarak değerlendirildi. Klavikula kırıkları sınıflandırılırken Edinburgh sınıflanması kullanıldı.[24] Edinburgh sınıflamasına göre proksimal klavikula kırıkları tip 1, distal klavikula kırıkları tip 3 ve diafiz kırıkları tip 2 olarak belirtilmiştir. Tip 2 kırıklar deplasman gösterdikleri zaman tip 2b olarak sınıflandırıldılar (Şekil 1a). Çalışmamıza çoklu travma (operasyon gerektiren çoklu kırıkları olan veya aynı taraf humerus kırıkları), 2 cm’den fazla kısalma, kırık hattında parçalanma ve tam ayrılma nedeniyle aynı cerrahi teknik ile tedavi edilmiş Edinburg tip 2b klavikula şaft kırıkları olan hastalar dahil edildi. Klavikula distal ile proksimal uç kırıkları, açık kırıklar, patolojik kırıklar, kaynama öncesi takibi tamamlamayan kırıklar, Edinburg tip 2a kırıklar ve akromiyoklaviküler eklem ayrışması olan olgular çalışmaya dahil edilmedi. Cerrahi, genel anestezi altında şezlong pozisyonunda yapıldı. Klavikulanın anterosuperior bölgesinden klavikulanın anatomik şekline uygun insizyon yapılarak minimal yumuşak doku hasarı ile kırık redüksiyonu sağlandı (Şekil 1b, c). Klavikulanın anatomik yapısına uygun olarak hazırlanmış olan 2.7 mm titanyum anatomik, kilitli klavikula plakları (Acumed, locking superior midshaft clavicle plates, USA®) (Şekil 1d) ile primer osteosentez iki farklı cerrah tarafından sağlanmıştı.

Cerrahi sonrasında basit kol askısı ile üst ekstremite istirahate sevk edilmişti. İlk üç hafta içerisinde pasif olarak dairesel omuz hareketleri ve izometrik deltoid egzersizleri başlanmıştı. Altıncı haftada aktif hareketlere sınırlama yapılmaksızın izin verilmişdi. Operasyondan üç ay sonra hastaların kademeli olarak spora dönmelerine izin verilmiş idi. Cerrahi sonrası olgular kaynama gerçekleşene kadar iki haftalık aralarla kaynama gerçekleşetikten sonra üç aylık dönemlerde ve birinci yıldan sonra ise senelik kontrole çağırılmış idi. Kaynama kontrollerde çekilen ön arka ve 15 derecelik sefalik direkt rayografi ile değerlendirilmiş idi. Radyolojik incelemede medial ve lateral kırık uçları arasında periosteal veya endosteal köprüleşmelerin görülmesi ve klinik olarak kırık bölgesinde ağrı ile instabilitenin görülmemesi tam kaynama olarak değerlendirildi. Geç kaynama 12 haftalık takiplerde ağrı ve instabilite ile beraber radyolojik incelemede kallus veya endosteal iyileşmenin görülmemesi olarak değerlendirildi. Aynı şekilde bir sene sonra şikayetlerin devam etmesi ve radyolojik iyileşmenin görülmemesi kaynamama olarak değerlendirildi. Klavikula kırıklarında kaynama elde edildikten sonra klinik değerlendirme hastalar kontrole çağrılarak Constant[25] ve DASH (Disabilities of the Arm, Shoulder and Hand)[26] skorlaması ile yapıldı.

(a)

(b)

(c)

(d)

Şekil 1. (a) Edinburg tip 2b kırığı olan hastanın operasyon öncesi kırığın yerleşimi ve insizyon hattı. (b) Klavikula kırık hattının ve kırık konfigürasyonun cerrahi sırasındaki görünümü. (c) Kırık hattında minimal doku hasarı ile beraber kırık redüksiyonu sonrası görünüm. (d) Kırık hattında redüksiyon sonrası minimal hasar ile Acumed superior anatomik klavikula plağının yerleştirilmesi. Redüksiyon sırasında ve plak yerleştirilmesinde periostun ve yumuşak doku bağlantılarının hasar görmemesine önem verilmiştir.

Ulus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, Sayı. 4

287

Akgül ve ark. Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları

BULGULAR Çalışmaya alınan 31 hastanın 32 klavikula cisim kırığının 17’si sağ ve 15’i sol taraf idi. Olguların 24’ü erkek, 7’si kadın ve ortalama yaş 28 (15-62) yıl idi. Hastaların ortalama takip süreleri 12.3 (6-36) ay olarak belirlendi.

12 haftadan sonra görüldü ve bu geç kaynama olarak değerlendirildi. Çalışmaya alınan hastalarda kaynama sonrası elde edilen ortalama Constant skorlaması 92 (85-98) ve DASH değerleri 9 (2-20) olarak belirlendi.

Çalışmaya alınan hastaların yedi tanesi ek kemik yaralanmaları olan çoklutravma hastası idi. Bu hastalara eşlik eden yaralanmalar pelvis kırığı (1), tibia kırığı (1), radius distal uç kırığı (2), kot kırığı (1), femur kırığı (1), torakal vertebra kırığı (1), humerus kırığı (1), hemotoraks (1), pnömotoraks (2) şeklinde idi.

Hastalarda klavikula kırığı cerrahisi sırasında komplikasyonla karşılaşılmamış idi. Takipleri sırasında 3/32 hastada (%9) klavikula üst kesiminde plağın iritasyonuna bağlı şikayetler gelişmiş idi. Bu hastalarda kaynama gerçekleşmesi üzerine implantlar çıkarılmıştı.

Klavikula kırıklarının tamamı 2.7 mm titanyum anatomik, kilitli klavikula plakları (Acumed, locking superior midshaft clavicle plates®, USA) ile primer osteosentez ile tedavi edilmiş idi. Klavikula kırıklarının yedi tanesinde iliak kanattan otogreft uygulaması yapılmış idi.

TARTIŞMA

Ortalama hastanede kalış süreleri 3.87 (2-10) gündü. Klavikula kırıkları ile beraber ek yaralanmalar yatış süresini uzatmakta idi. İzole klavikula kırıklarında hastanede yatış süresi üç (2-4) gün olarak belirlendi. Olguların tamamında tam kaynama sağlandı (Şekil 2). Çekilen ön-arka ve 15 derecelik sefalik direkt radyografilerde ortalama kaynama süresi 15.2 (12-20) hafta olarak belirlendi. Tip 2 b2 kırığı olan hastalardan üç tanesinde (%9.4) kırık kaynaması

(a)

(b)

Şekil 2. (a) Sol klavikula Edinburg tip 2 kırığı olan hastanın operasyon öncesi ön arka planda çekilen röntgen görüntüsü. (b) Operasyon sonrası altıncı ayda çekilen kontrol ön arka grafisinde kırık hattında tam kaynama görülmekte.

288

Klavikula cisim kırıklarında ilk olarak Neer konservatif tedavi ile düşük komplikasyon ve yüksek kaynama oranı bildirmiştir. [5] 1997 yılında ise Hill ve ark., klavikula kırıkları ile yaptıkları konservatif tedavi çalışmasında %15 oranında kaynamama ve kısalık olmasını risk faktörü bildirmişlerdir.[27] Nowak ve ark. ise klavikula kırıkları ile yaptıkları ileriye yönelik çalışmada kaynamama için olası risk faktörlerini kırık sahada kemik kontağının kaybolması, transvers kırıklar ve ileri yaş olarak belirlemişlerdir.[16] Zlowodzki ve ark.[11] ise konservatif tedavi ile %6 kaynamama bildirmekle beraber kaynamama için risk faktörlerini deplase kırıklar, parçalı kırıklar, kadın cinsiyet ve ileri yaş olarak bildirmişlerdir. McKee ve ark.nın[10] deplase klavikula kırıklarında konservatif ve cerrahi tedaviyi karşılaştırdıkları meta analiz çalışmasında konservatif tedavi edilen hastalarda kaynamama oranı %15 iken cerrahi tedavi edilen olgularda bu oran %1 olarak belirtilmiştir. Bu meta analizde cerrahi tedavi sonrasında ağrıların erken dönemde azalması ile beraber daha iyi fonksiyonel sonuçların elde edildiği bildirilmiştir. Cerrahi tedavi üzerine yapılan çalışmalarda plak vida uygulamaları, pin uygulamaları ve eksternal fiksatör uygulamaları ile başarılı sonuçlar bildirilmiştir.[16,17,22,23] Demirhan ve ark.[18] kadavra klavikulalarında yaptıkları deneysel çalışmada, kırık stabilizasyonunda plak vida yönteminin diğer osteosentez materyallerine göre daha stabil olduğunu göstermişlerdir. Kilitli klavikula plakları ile klasik dinamik kompresyon plaklarını karşılaştıran klinik çalışmalarda da kilitli anatomik plakların daha başarılı olduğu gösterilmiştir.[16,17] Yapılan biyomekanik çalışmalarda kilitli plakların konvansiyonal plaklara göre biyomekanik olarak daha stabil olduğunu göstermektedir.[22,23] Literatürde klavikula kırıklarında plak vida uygulamaları ile yüksek kaynama oranı bildirilmiştir (Tablo 1).[9,12-15,19-21] Böstman ve ark.,[15] konvansiyonel plak vida ile yaptıkları klavikula osteosentezleri ile 14/103 hastada kaynamama bildirmişdir. Chen ve ark.[28] tubuler plak ile yaptıkları klavikula osteosentezi sonrasında ortalama 24 haftada %95 oranında kaynama bildirmiştir. Kilitli plak ile yapılan çalışmalarda kaynama oranı Ulus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, Sayı. 4

Akgül ve ark. Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları

Table 1.

Klavikula kırıklarının cerrahi tedavi sonuçlarını veren yayınların ve çalışmamızın radiyolojik ve klinik sonuçları

Çalışma Tarih Hasta Yaş ortalama sayısı (yıl)

Kullanılan implant

Kaynama Cerrah süresi (hafta) sayısı

Takip Komplikasyon süresi

Fonksiyonel sonuç

Fridberg ve ark.[20]

2013

105

LCP Anat.

–

0.5-3.5 yıl

%23 (24/105)

–

Cho ve ark[17]

2010

LCP Anat. (23)

DCP (14.6)

–

11.9 ay

%45 (DCP)

33.8 (DCP)*

%27 (LCP)

34.8 (LCP)*

–

4.2**

Lee ve ark.

2013

Mirzatolooei

2011 29

Jiang ve ark.

2012

[30]

[14]

[21]

14 64

DCP (19) LCP (indirekt)

LCP (13.3) 15.6

DCP MIPO (32) LCP Anat (32)

– MIPO (12)

1 – –

17.6 ay – 15 ay

LCP (13)

%30 MIPO (%6)

8.6** 6**

LCP (%20)

Ozler ve ark.

2012

39.6

LCP Anat.

13.3

–

34.6 ay

%25

12.8**

VanBeek ve ark.

2011

28.9

LCP (14)

–

7.1 yıl

%64

98.3***

LCP Anat. (28)

3.4 yıl

%40

94***

[19]

[29]

Böstman ve ark. [15]

1997

103

36 33,4

DCP (55)

Tubuler (2)

Recon. (46)

Chen ve ark. [28]

Akgül ve ark.

–

23 ay

%23

–

2008

111

Semitubuler

–

3.5 yıl

%10

10.3**

–

LCP Anat.

15.2

12.3 ay

9**

*Quick DASH (Quick Disabilities of the Arm, Shoulder and Hand) **DASH (Disabilities of the Arm, Shoulder and Hand) ***ASES; American Shoulder Elbow Surgery, LCP: Kilitli Plak; DCP: Dinamik kompresyon plağı; MIPO: Minimal invaziv perkütan osteosentez; Anat: Anatomik.

%95 ile %100 arasında bildirilmiştir.[19-21,29,30] Çalışmamızda açık repozisyon ve anatomik kilitli klavikula plak uygulamaları sayesinde yüksek kaynama ve erken-iyi fonksiyonel sonuç elde edildi. Klinik sonuçlarımız literatürde bildirilen diğer çalışmalar ile benzerlik göstermekte idi.[18-20,28,29] Mirzatolooei[14] yaptığı çalışmada dört hastada yanlış kaynama bildirilmiştir. Yanlış kaynamanın en önemli sebepleri arasında anatomik plak kullanmaması olduğunu düşünmekteyiz. VanBeek ve ark.[29] kilitli plak ve anatomik kilitli plakları karşılaştırdıkları yayınlarında anatomik kilitli plak kullanımı ile daha az komplikasyon geliştiğini bildirmişlerdir. Biz çalışmamızda yanlış kaynama görülmemesinin sebebleri arasında anatomik kilitli plak kullanımı ile dizilimin sağlanmış olması yatmaktadır. Lee ve ark.[30] klavikula kırıkları tedavisinde kilitli plak ile indirekt redüksiyon sonrası sadece dizilimin sağlanması ile başarılı sonuçlar bildirmiştir. Kilitli plak uygulanan çalışmalarda en geniş çalışma Fridberg ve ark.nın[20] yaptıkları, dört farklı plak ve iki farklı yerleşim yolu kullandıkları 114 hastalık çalışmadır. Çalışmaya alınan tüm hastalarda kaynama sağlanmış ve yanlış kaynamaya rastlanmamıştır. Jiang ve ark.[21] yaptıkları kilitli plak çalışmasında kaynamanın oranının yüksek olduğunu bununla beraber minimal hasarlı uygulanan plaklarda daha iyi kozmetik sonuç verdiğini bildirmişlerdir. Çalışmamız izole klavikula orta diafiz kırıklarında superior yerleşimli tek çeşit anatomik plak uygulanan geniş serilerden biridir. Literatürde klavikula kırıklarında plak uygulanan çalışmalarda %5 ila %50 arasında implanta bağlı komplikasyonlar bildirilUlus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, Sayı. 4

miştir ancak bizim çalışmamızda %9 oranında implant bağımlı komplikasyon görülmüştür.[9,11-15,19-21,29,30] Klavikula orta diafiz deplase ve parçalı kırıklarında anatomik kilitli plaklar yardımı ile minimal doku hasarıyla mükemmel radyolojik ve fonksiyonel sonuçlar elde etmek mümkündür. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-84. 2. Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127-32. 3. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6. 4. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70:461-4. 5. Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:100611. 6. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42. 7. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;58:71-4. 8. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-10. 9. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.

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Akgül ve ark. Klavikula Edinburg tip 2 cisim kırıklarının cerrahi tedavisinde düşük profilli anatomik kilitli plak uygulaması sonuçları 10. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85-A:790-7. 11. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD; Evidence-Based Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2005;19:504-7. 12. Virtanen KJ, Paavola MP, Remes VM, Pajarinen J, Savolainen V, Bjorkenheim JM. Nonoperative versus operative treatment of midshaft clavicle fractures: a randomized controlled trial. Read at the 75th Annual Meeting of the AAOS; 2010 Mar 9-12; New Orleans, LA. Paper no 331. 13. Smith CA, Rudd J, Crosby LA. Results of operative versus nonoperative treatment for 100% displaced midshaft clavicle fractures: a prospective randomized clinical trial. Read at the 16th Annual Open Meeting of the American Shoulder and Elbow Surgeons; 2000 Mar 18; Orlando, FL. Paper no 31. 14. Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc 2011;45:34-40. 15. Böstman O, Manninen M, Pihlajamäki H. Complications of plate fixation in fresh displaced midclavicular fractures. J Trauma 1997;43:778-83. 16. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 2005;76:496502. 17. Cho CH, Song KS, Min BW, Bae KC, Lee KJ. Operative treatment of clavicle midshaft fractures: comparison between reconstruction plate and reconstruction locking compression plate. Clin Orthop Surg 2010;2:1549. 18. Demirhan M, Bilsel K, Atalar AC, Bozdag E, Sunbuloglu E, Kale A. Biomechanical comparison of fixation techniques in midshaft clavicular fractures. J Orthop Trauma 2011;25:272-8. 19. Ozler T, Güven M, Kocadal AO, Uluçay C, Beyzadeoğlu T, Altıntaş F. Locked anatomic plate fixation in displaced clavicular fractures. Acta Orthop Traumatol Turc 2012;46:237-42.

20. Fridberg M, Ban I, Issa Z, Krasheninnikoff M, Troelsen A. Locking plate osteosynthesis of clavicle fractures: complication and reoperation rates in one hundred and five consecutive cases. Int Orthop 2013;37:689-92. 21. Jiang H, Qu W. Operative treatment of clavicle midshaft fractures using a locking compression plate: comparison between mini-invasive plate osteosynthesis (MIPPO) technique and conventional open reduction. Orthop Traumatol Surg Res 2012;98:666-71. 22. Little KJ, Riches PE, Fazzi UG. Biomechanical analysis of locked and non-locked plate fixation of the clavicle. Injury 2012;43:921-5. 23. Celestre P, Roberston C, Mahar A, Oka R, Meunier M, Schwartz A. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability? J Orthop Trauma 2008 Apr;22:2417. 24. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-84. 25. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4. 26. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG) Am J Ind Med 1996;29:602-8. 27. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9. 28. Chen CH, Chen JC, Wang C, Tien YC, Chang JK, Hung SH. Semitubular plates for acutely displaced midclavicular fractures: a retrospective study of 111 patients followed for 2.5 to 6 years. J Orthop Trauma 2008;22:463-6. 29. VanBeek C, Boselli KJ, Cadet ER, Ahmad CS, Levine WN. Precontoured plating of clavicle fractures: decreased hardware-related complications? Clin Orthop Relat Res 2011;469:3337-43. 30. Lee HJ, Oh CW, Oh JK, Yoon JP, Kim JW, Na SB, et al. Percutaneous plating for comminuted midshaft fractures of the clavicle: a surgical technique to aid the reduction with nail assistance. Injury 2013;44:465-70.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

The results of low profile locking anatomical plate application for the treatment of Edinburg type 2 clavicle diaphysis fractures Turgut Akgül, M.D.,1 Sinan Zehir, M.D.,2 Güzelali Özdemir, M.D.,3 Ferit Yücel, M.D.,5 Abdulkadir Türk, M.D.,4 Özgür Çiçekli, M.D.4 Department of Orthopaedics and Traumatology, İstanbul University İstanbul Faculty of Medicine, İstanbul; Department of Orthopaedics and Traumatology, Hitit University Faculty of Medicine, Çorum; 3 Department of Orthopaedics and Traumatology, Fatih Sultan Mehmet Training Hospital, İstanbul; 4 Department of Orthopaedics and Traumatology, Şanlıurfa Training Hospital, Şanlıurfa; 5 Edesa Hospital, Şanlıurfa 1 2

BACKGROUND: Although conservative measures are the general choice of treatment for clavicle fractures; surgery is advised for displaced and multifragmentary fractures. Open reduction and osteosynthesis with a plate-screw combination are used widely as surgical treatment options. METHODS: In our study, there were 21 patients with Edinburgh Type IIB clavicle middiaphysal fractures treated surgically with locked anatomical clavicle plate. RESULTS: Among those 31 patients and 32 clavicle middiaphysal fractures, Seventeen clavicle fractures were right-side, and fifteen were left side. 24 of them were males, 7 of them were females and the mean age was 28 (15-62) years. The mean follow-up period was 12.3 (6-36) months and healing time 15.2 (12-20) weeks. 3 patients with Type IIB fracture had a healing time longer than 12 weeks. As the result of healing patients’, mean constant score was 92 (85-98) and DASH score 9 (2-20). There has been a problem due to the implant detected in 3 (9%) patients. DISCUSSION: Successful functional and radiographic results can be achieved as a result of the surgical treatment of the clavicle middiaphysal fractures with locked anatomical plates. Key words: Clavicle middiaphysal fractures; locked anatomic clavicle plate. Ulus Travma Acil Cerrahi Derg 2014;20(4):286-290

290

doi: 10.5505/tjtes.2014.88303

Ulus Travma Acil Cerrahi Derg, Temmuz 2014, Cilt. 20, Sayı. 4

CA S E R EP O RT

Ergotamine-induced vasospastic ischemia mimicking arterial embolism: unusual case Gürhan Adam, M.D.,1 Tolga Kurt, M.D.,2 Celal Çınar, M.D.,3 Abdullah Sarıyıldırım, M.D.,1 Mustafa Resorlu, M.D.,1 Fatma Uysal, M.D.,1 Ali Ümit Yener, M.D.,2 Sedat Özcan, M.D.,2 Mustafa Saçar, M.D.,2 Hüseyin Özdemir, M.D.1 1

Department of Radiology, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale;

Department of Cardiovascular Surgery, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale;

Department of Radiology, Ege University Faculty of Medicine, Izmir

ABSTRACT Ergotamine toxicity is an important and rare condition, including tachycardia, arterial spasm which occurring as a result of accidental overdosing or drug interactions. We assessed the consequences of delayed diagnosis of peripheral arterial vasoconstriction occurring after simultaneous macrolide use by a 35-year-old woman using an ergot-derived drug for migraine. Diagnosis of ergotamine intoxication begins with suspicion. Interventional radiologists and surgeons should be aware of this acute dangerous condition. Key words: Acute arterial emboli; ergotamine; vasospasm.

INTRODUCTION Ergot alkaloids are widely used drugs in the treatment and prophylaxis of migraine headache. Ergotamine-induced vasospastic ischemia is a rare, but important complication of these drugs including hypertension, tachycardia, and arterial spasm.[1] The lower extremities are the most commonly involved part of the body and this condition may present as an acute arterial embolism that requiring endovascular intervention. Furthermore, delayed diagnosis can be caused of serious irreversible complications. We know that several agents, such as macrolides may raise the level of serum ergotamines and its toxic effects. In this study, we assessed the consequences of delayed diagnosis of peripheral arterial vasoconstriction occurring after simulta-

Address for correspondence: Gurhan Adam, M.D. Cumhuriyet Mahallesi, Alpaslan Turkeş Sokak, No: 5, Daire: 13, Kepez, Çanakkale, Turkey Tel: +90 286 - 218 00 18 E-mail: gurhanadam@hotmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

neous macrolide use by a 35-year-old woman taking an ergotamine-derived drug for migraine.

CASE REPORT A 35-year-old woman presented to our emergency department with the complaint of worsening pain and pallor in the left foot that started 2 days before. The patient’s history revealed that she had been a heavy smoker for 10 years and had received a single 1 g dose of azithromycin due to a genital infection 4 days previously. In the left, peripheral pulses could not be measured at physical examination, and the foot was pale and sensitive. Wide loss of calibration and monophasic flow forms were observed in the left side arteries at color Doppler ultrasound. Acute arterial embolism was suspected, heparin was started at 1000 IU/hour, and the patient was taken for emergency arterial embolectomy of the lower left extremity. During thrombectomy, surgeons recognized diffuse narrowed calibration of the femoral artery, but all the arteries were patent without thromboemboli. Angiography of the lower extremity was performed because of the no thrombotic material emerged from the distal arterial bed. Angiographic images revealed decreased calibration in the entire arterial system in the lower right extremity (Fig. 1). Crural arteries on the left side could not be observed in some places, while the observed sections were finely calibrated. Normal calibration was seen in the proximal arteries on the left, embolectomized side. Right embolectomy was performed following development of similar symptoms on the right side. 291

Adam et al. Ergotamine-induced vasospastic ischemia mimicking arterial embolism

Figure 1. Angiography of the right lower extremity arteries demonstrate thread-like narrowing in the all lower arteries (upper series), after treatment of heparin and embolectomy, right sided angiography shows normal calibration of all arteries (lower series).

Ergot-induced arterial spasm was not considered at the beginning, because she did not explain this before angiography. However, detailed anamnesis revealed that she has had migraine and was on long-term ergotamine use in addition to azithromycin for 4 days ago. We suspected that the symptoms might be vasospastic in origin and related to ergotamine use, and ergotamine was stopped. Heparin at 1000 IU/hour continued to be used for 7 days. Clinical findings improved, and vasospasm resolved completely at 5th day control angiography (Fig. 2). She was informed about ergotamine-related symptoms that might occur and discharged. No problem was encountered at 6 months follow-up.

DISCUSSION The toxicity level in patients using ergot alkaloids is estimated to be as low as 0.001-0.002%.[2] The vascular side-effects have been associated with ergotamine toxicity resulting from therapeutic doses in patients with oversensitivity, various drug interactions or overdosing.[3,4] Our patient took ergotamine in a therapeutic dose, and a macrolide group drug was added to treatment due to urinary tract infection. Vascular ischemia in ergotamine toxicity may lead to severely complicated conditions through alpha adrenergic and antiserotonergic activity and vasospasm and thrombus formation. Although the arteries of the lower extremities are most frequently affected, coronary, mesenteric, splenic, re292

nal, and retinal arterial spasms have also been reported.[5,6] Bilateral lower extremity arterial structures were affected in our patient. In ergot intoxication, color Doppler ultrasound findings suggest diffuse spasm, in the form of loss of calibration, together with an increased flow rate in the arteries. Most patients therefore require angiographic examination. Diffuse and segmental spasm is observed in vascular structures at angiography. Findings are generally symmetrical and show that both lower extremities are affected.[7] Since ergot intoxication is rare, these non-specific clinical findings are inadequate for diagnosis. In that context, radiological findings in combination with clinical findings and deep anamnesis become significant. Conditions such as fever, sepsis, malnutrition, thyrotoxicosis, pregnancy, liver and kidney insufficiencies, coronary artery disease and peripheral vascular disease increase the toxic effects of ergotamine.[8] Drugs such as oral contraceptives, propranolol, xanthine derivatives, antiviral and antiretroviral agents and antibiotics that affect the metabolism of ergotamine in the liver (including erythromycin, clarithromycin, and ampicillin) may cause an increase in the effects of ergotamine.[7,9] In addition, conditions such as Buergerâ&#x20AC;&#x2122;s disease and Reynaudâ&#x20AC;&#x2122;s phenomenon must be considered at diagnosis. These angiographic and clinical findings differ from ergotamine intoxication.[10] Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Adam et al. Ergotamine-induced vasospastic ischemia mimicking arterial embolism

Figure 2. Angiography of the left lower extremity shows normal size of the superficial femoral artery, embolectomized side. The distal portions of the popliteal artery exhibit severe vasospasm (upper series). Angiographic findings of the left lower extremity arteries show normal calibration following treatment of heparin and embolectomy. Left sided angiography shows normal calibration of the all arteries (lower series).

Treatment of ergotamine toxicity diagnosed in the light of clinical and radiological findings begins with stopping the drug. Findings will generally be seen to improve. In resistant cases, however, treatment is planned with various vasodilator and anticoagulant drugs (nitroprusside, prazosin, tolazoline, thymoxamine HCl, streptokinase, calcium channel blockers, the application of intra-arterial prostaglandin E1, intravenous heparin, nitroglycerin or intra-arterial nifedin).[11] Arterial spasm generally restricts and resolves itself with medical treatment. On rare occasions, medical treatment may be insufficient, in which case intra-arterial balloon dilation and surgery or chemical sympathectomy procedures may be regarded as effective. Peripheral balloon angioplasty, atherectomy and other procedures effective in resolving arterial spasm may lead to permanent damage in the arterial bed. Our case presented with findings of acute arterial embolism. Since claudication was described as intermittent at anamnesis, acute chronic arterial blockage was considered, and ergotamine intoxication was not suspected. Loss of calibration in the lower extremity arteries at colored Doppler ultrasound was suggestive of vasospasm, but since ergotamine intoxication is rare it was not considered at diagnosis. Therefore, embolectomy was performed immediately for treatment of the ischemic condition of the patientâ&#x20AC;&#x2122;s lower extremity. Detailed history revealed that she had been taking ergotamine for 3 years. Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Peripheral balloon angioplasty, atherectomy and other procedures alongside medical treatment have been reported to eliminate vasospasm in patients diagnosed with ergotamine intoxication. However, since there is a risk of this causing permanent damage to normal arteries, their use is not primarily recommended in the absence of necrosis and gangrene.[7] Consecutive embolectomies were performed due to the delay in diagnosing our patient. Diagnosis of ergotamine intoxication begins with suspicion. Diagnosis can then be established by deepening anamnesis, particularly in patients not at risk of vascular diseases. Interventional radiologists and surgeons should be aware of this acute dangerous condition. Conflict of interest: None declared.

REFERENCES 1. Kim MD, Lee G, Shin SW. Ergotamine-induced upper extremity ischemia: a case report. Korean J Radiol 2005;6:130-2. 2. Paraskevopoulos JA, Teasdale DE, Cuschieri RJ. Severe reversible arterial spasm with ergotamine. Br J Clin Pract 1995;49:214. 3. Garcia GD, Goff JM Jr, Hadro NC, Oâ&#x20AC;&#x2122;donnell SD, Greatorex PS. Chronic ergot toxicity: A rare cause of lower extremity ischemia. J Vasc Surg 2000;31:1245-7. 4. Cervi E, Bonardelli S, Battaglia G, Gheza F, Maffeis R, Nodari F, et al. Upper limb artery segmental occlusions due to chronic use of ergota-

293

Adam et al. Ergotamine-induced vasospastic ischemia mimicking arterial embolism mine combined with itraconazole, treated by thrombolysis. Thromb J 2011;9:13. 5. Voyvodic F, Hayward M. Case report: upper extremity ischaemia secondary to ergotamine poisoning. Clin Radiol 1996;51:589-91. 6. Dal Verme A, López E, Grinspon S, Fernández Pardal R, Mengia M, Mazzocchi O. Splenic infarction. Ergotism induced by ritonavir?. [Article in Spanish] Medicina (B Aires) 2012;72:475-7. [Abstract] 7. McKiernan TL, Bock K, Leya F, Grassman E, Lewis B, Johnson SA, et al. Ergot induced peripheral vascular insufficiency, non-interventional treatment. Cathet Cardiovasc Diagn 1994;31:211-4.

8. Wells KE, Steed DL, Zajko AB, Webster MW. Recognition and treatment of arterial insufficiency from cafergot. J Vasc Surg 1986;4:8-15. 9. Fukui S, Coggia M, Goëau-Brissonnière O. Acute upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin. Ann Vasc Surg 1997;11:420-4. 10. Pope JE. The diagnosis and treatment of Raynaud’s phenomenon: a practical approach. Drugs 2007;67:517-25. 11. Demir S, Akin S, Tercan F, Ariboğan A, Oğuzkurt L. Ergotamine-induced lower extremity arterial vasospasm presenting as acute limb ischemia. Diagn Interv Radiol 2010;16:165-7.

OLGU SUNUMU - ÖZET

Arteriyel emboliyi taklit eden ergotamine bağlı vazospastik iskemi: Nadir bir olgu Dr. Gürhan Adam,1 Dr. Tolga Kurt,2 Dr. Celal Çınar,3 Dr. Abdullah Sarıyıldırım,1 Dr. Mustafa Resorlu,1 Dr. Fatma Uysal,1 Dr. Ali Ümit Yener,2 Dr. Sedat Özcan,2 Dr. Mustafa Saçar,2 Dr. Hüseyin Özdemir1 1 2 3

Çanakkale Onsekiz Mart Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Çanakkale; Çanakkale Onsekiz Mart Üniversitesi Tıp Fakültesi, Kardiyovasküler Cerrahi Anabilim Dalı, Çanakkale; Ege Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İzmir

Ergotamin zehirlenmesi, yanlışlıkla aşırı doz alımına ya da ilaç etkileşimleri sonucunda ilaç etkinliğinin artmasıyla ortaya çıkan taşikardi, arteriyel spazm gibi bulguları olan ciddi ve nadir bir durumdur. Bu yazıda Migren için bir ergot türevi ilaç kullanan 35 yaşındaki olgunun, eşzamanlı makrolid kullanımın oluşturduğu, periferik arteriyel vazokonstrüksiyonun gecikmiş tanı sonuçlarını değerlendirdik. Anahtar sözcükler: Anjiografi; ergotamine; iskemi. Ulus Travma Acil Cerrahi Derg 2014;20(4):291-294

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CA S E R EP O RT

Successful surgical rescue of delayed onset diaphragmatic hernia following radiofrequency ablation for hepatocellular carcinoma Tsukasa Nakamura, M.D.,1,2 Koji Masuda, M.D.,2 Rajveer Singh Thethi, M.D.,3 Hirotaka Sako, M.D.,2 Takaharu Yoh, M.D.,4 Toshimasa Nakao, M.D.,1 Norio Yoshimura, M.D.1 1

Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan;

Department of Surgery, 4Gastroenterology and Hepatology, Omihachiman Community Medical Center, Shiga, Japan;

Department of Hepatobiliary and Pancreatic Surgery, St. Jamesâ&#x20AC;&#x2122;s University Hospital, Leeds, United Kingdom

ABSTRACT Radiofrequency ablation (RFA) has been established as the mainstay therapy for hepatocellular carcinoma (HCC) in patients deemed unsuitable for surgical resection. However, delayed diaphragmatic hernia can occur as a result of this procedure. There have been only seven other cases reported on this complication in the literature. Considering the recent growth in the popularity of the procedure, it is predictable that the incidence of the diaphragmatic hernia, due to RFA, will definitely increase. This case report is therefore vitally important as it increases clinical awareness of this currently rare complication, which could lead to improved survival rates in these patients. This case concerns an 81-year-old Asian man with a past medical history of cirrhosis and HCC (segment IV and VIII) who presented with a delayed, right diaphragmatic hernia and strangulated ileus 18 months after his original RFA procedure. It is important to implement extra measures to limit the risk of diaphragmatic, thermal injuries when RFA is performed. In particular, gastroenterologists, surgeons and accident and emergency staff should all be aware of this complication proceed with rapid diagnosis and management when patients, who previously underwent RFA, present with acute abdominal pain. Key words: Delayed onset; diaphragmatic hernia; hepatocellular carcinoma; radiofrequency ablation.

Radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) has gained significant popularity and interest among clinicians since its original introduction in 1995. Although the utilization of RFA for HCC has been shown to carry a poorer prognosis when compared to hepatectomy, RFA is now classified as the mainstay therapy for HCC in patients unsuitable for surgery.

tions; and systemic complications. Intrahepatic complications include injury to the hepatic duct, portal vein, hepatic artery, and hepatic vein. Extrahepatic complications include pleural effusion, ascites, and injury of the abdominal wall. Reported systemic complications include hepatic failure, acute respiratory failure, etc. Among these complications, delayed diaphragmatic hernia following RFA is quite rare. In this article, we report the case of a delayed diaphragmatic hernia, which subsequently caused strangulated ileus due to RFA for HCC.

Common complication of RFA can be divided into three categories: intrahepatic complications; extrahepatic complica-

CASE REPORT

INTRODUCTION

Address for correspondence: Tsukasa Nakamura, M.D. Kajii-cho 465, Kamigyo-ku Kyoto, Japan Tel: 81752515532 E-mail: tsukasa@koto.kpu-m.ac.jp Qucik Response Code

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An 81-year-old man with a medical history of cirrhosis, HCC (segment [S] IV and VIII) due to hepatitis C complained of severe right upper quadrant (RUQ), abdominal pain and dyspnea. He had undergone RFA 18 months ago for S IV and VIII HCC measuring 19 and 24 mm, respectively, following transcatheter arterial embolization which had been performed 20 months earlier. Ultrasonographic guided RFA had been performed by means of a cool-tip radiofrequency probe (3 cm electrode, 15 cm length). The ablation for S VIII was approached from the epigastric fossa and involved three ses295

Nakamura et al. Successful surgical rescue of delayed onset diaphragmatic hernia following RF ablation for hepatocellular carcinoma

sions. Similarly, the S IV lesion was ablated twice. Each procedure did not cause any immediate, major complications. Magnetic resonance imaging and computed tomography (CT) was performed 3 months later in order to confirm the effectiveness of the RFA treatment and rule out any other lesions. These diagnostic imaging techniques did not reveal diaphragmatic injuries (DI). He was admitted to our hospital with acute onset, severe, RUQ pain that started 8 hours previously and that remained constant in nature. He had no history of acute or traumatic injury. Arterial blood gas results revealed a reduced partial oxygen pressure (pO2): 75.6 mmHg. A chest US detected distended bowel loops in the right thoracic cavity. Furthermore, following a CT scan, it was confirmed that there was a right diaphragmatic hernia containing strangulated small intestine (Fig. 1). Subsequently, the patient underwent an emergency diaphragmatic hernia repair and small bowel resection. There was a diaphragmatic hernia located in close, anatomical proximity to the S VIII HCC (Fig. 2a). Surgical visualization of the right hepatic lobe indicated significant atrophy as a result of chronic cirrhosis. Approximately 1 m of small bowel

was found to have been incarcerated through a 5 cm defect of the right diaphragm (Fig. 2b and c). Via an incision of the hernial orifice, the incarcerated bowel was released, and the ischemic bowel was resected; after which the right diaphragm was repaired by using 3-0 prolene sutures in an interrupted manner (Fig. 2d). As his clinical course was stable and uncomplicated, he was discharged after 15 days of hospitalization. Currently, the patient is systemically well and with no signs of hernia.

DISCUSSION RFA has gained popularity and has now become the mainstay procedure for HCC. Therefore, it can be argued that, although presently small, the incidence of complications such as diaphragmatic hernias as a result of RFA will inevitably increase. Diaphragmatic hernia following RFA procedure can be categorized as DI. Delayed diagnosis of DI possibly lead to poor prognosis compared to early diagnosis: namely 30% (delayed) and 7.1% (early), respectively.[1] Interestingly, right-sided and left-sided DI might show a different outcome: right-sided DI face higher risk for strangulation than left-sided.[2] According to these discussions, it is a vital point to confirm early

(a)

(b)

(c)

(d)

Figure 1. Computed tomography (CT) scan demonstrating the right diaphragmatic hernia. The hernial orifice was located in close proximity to the site of the segment (S) VIII hepatocellular carcinoma (HCC). (a) Chest radiograph, (b) horizontal enhanced CT scan, (c and d) sagittal enhanced CT scan. Figure 1b Yellow arrow head: strangulated small intestine in the right thoracic cavity, Figure 1c Yellow arrow head: diaphragmatic hernial orifice, white arrow: S VIII HCC.

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Nakamura et al. Successful surgical rescue of delayed onset diaphragmatic hernia following RF ablation for hepatocellular carcinoma

(a)

(b)

(c)

(d)

Figure 2. (a) Diaphragmatic hernia: small intestine was strangulated by the defect of the right diaphragm. (b) Strangulated small intestine demonstrated an irreversible, ischemic injury. (c) The defect size was roughly 5 cm. (d) The defect was closed with 3-0 prolene, interrupted sutures.

diagnosis of diaphragmatic hernia due to RFA where most of the reported lesions are located at right-sided as discussed in detail later, given difficulties of early diagnosis and leathal outcomes, Pekmezci et al.[3] had reported that thoracoscopy was an effective tool for the diagnosis, including subsequent surgical repair of DI. Furthermore, it is also capable of eliminating pleural collections which might cause pyothorax. Therefore, when the diagnosis is uncertain, thoracoscopy should be recommended. It is also noteworthy that this patient developed a diaphragmatic hernia 18 months after the initial RFA procedure. All eight cases of delayed onset diaphragmatic hernia following RFA in the international literatures[4-9] have patients presenting with severe, abdominal pain between 9 and 20 months after their RFA procedure (Table 1). Furthermore, all eight cases describe RFA for HCC in S V-VIII which are in close proximity to the right diaphragm. Therefore, there seems to be a correlation between the increased incidence of diaphragmatic hernias, the anatomical location of the HCC lesions and their distance from the diaphragm. The onset of the diaphragmatic hernia with strangulated ileus seems to have a possible risk factor: Chilaiditi syndrome is defined as the transposition of colon between the diaphragm and liver. The condition generally involves the transverse colon, but Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

can also refer to the small intestine. Chilaiditi syndrome usually remains as an asymptomatic, anatomical variant and is normally identified as an incidental radiological finding, when it is referred to as the Chilaiditi sign. It can occur as a direct result of abnormalities of the falciform or suspensory ligaments of the transverse colon or congenital transposition.[10] Furthermore, in the case of cirrhotic patients, the incidence of Chilaiditi syndrome inevitably increases, because the right lobe has a propensity to atrophy due to the cirrhosis and the subsequent generation of the space between the diaphragm and liver.[11] In our case, his standard liver volume was 1061 ml according to the Urata formula,[12] and his actual liver volume based on CT scan was 1009 ml. However, his right liver volume occupied just 50% of total due to cirrhotic atrophy, which was significantly smaller size compared to the standard size. Thus, it can be argued that when diaphragmatic hernia happens on cirrhotic patients, the incidence of subsequent strangulated ileus should be higher than on patients presenting without cirrhosis. In fact, Shibuya et al.[5] had indicated the patients demonstrated Chilaiditi syndrome before the onset of diaphragmatic hernia with strangulated ileus. Although there was no evidence of Chilaiditi syndrome in our case, it is important to be aware of its existence, whether the cirrhotic patients who underwent RFA demonstrate Chilaiditi syndrome or not. 297

Nakamura et al. Successful surgical rescue of delayed onset diaphragmatic hernia following RF ablation for hepatocellular carcinoma

Table 1. Summary of previous reported delayed diaphragmatic hernia following RFA for HCC Reference Age Segment affected CP score score Onset of RFA Strangulated by HCC and and MELD defect needle ileus/prognosis medical history (months)

Thoracic cavity or intraperitoneal saline infusion/intraabdominal carbon dioxide

Koda et al., 2003[4]

No information

IV, VI, VII, VIII

CP 9 (Class B)

HBV related

MELD unknown

Le veen

Existed/recovered well, but 1 month

later died of hemorrhage

due to rupture of HCC

Shibuya et al., 2006[5]

Existed/patient

IV, VIII Alcoholic

CP unknown

liver cirrhosis

MELD unknown

di Francesco et al., 2008[6] 49

VII

Nawa et al., 2010[7]

VIII

Yamagami et al., 2011[8]

Singh et al., 2011[9]

RITA

Cool-tip No/patient recovered well

CP 6 (Class A)

Existed/patient

RITA

MELD 9

VII HCV related

CP 7-9 (Class B)

liver cirrhosis

MELD - unknown

II-III and V-VIII

CP 5-6 (Class A)

MELD 2

related liver cirrhosis

IV, VIII HCV related

CP 6 (Class A)

MELD 2

No/No No information

recovered well

Cool-tip No/patient

liver cirrhosis

No/No

recovered well

Cool-tip No/patient

alcoholic and HBV

No information

recovered well

MELD unknown

Nakamura et al., 2014

CP unknown

No information

recovered well

Cool-tip Existed/patient

No/No

recovered well

HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus; CP: Child–Pugh; MELD: Model for end-stage liver disease; RFA: Radiofrequency ablation; RTIA: Radiofrequency interstitial tissue ablation.

When RFA is utilized for HCC in close proximity to the diaphragmatic surface of the liver: S IV, VII, and VIII, it is necessary to protect the diaphragm in order to avoid the potentially lethal complications of a diaphragmatic hernia. Therefore, it is advised that before RFA is initiated, the use of either intraabdominal carbon dioxide, thoracic cavity or intraperitoneal carbon dioxide is warranted. In general, it can be argued that intraperitoneal saline infusion is more effective than intrathoracic cavity saline infusion in terms of the risk of developing diaphragmatic injury.[13] It is of vital importance to make a rapid and accurate assessment of any patient, who having had previous RFA, complains of acute abdominal pain. Thoracoscopy should be performed as the occasion demands. As a result of this report, we would like to make clinicians more aware of the increasing incidence diaphragmatic hernias as possible complications of RFA for HCC. This can lead to improved patient survival rates from RFA.

Ethical Approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Conflict of interest: None declared. 298

REFERENCES 1. Demetriades D, Kakoyiannis S, Parekh D, Hatzitheofilou C. Penetrating injuries of the diaphragm. Br J Surg 1988;75:824-6. 2. Zierold D, Perlstein J, Weidman ER, Wiedeman JE. Penetrating trauma to the diaphragm: natural history and ultrasonographic characteristics of untreated injury in a pig model. Arch Surg 2001;136:32-7. 3. Pekmezci S, Kaynak K, Saribeyoğlu K, Memişoğlu K, Kurdal T, Kol E, et al. Thoracoscopy in the diagnosis and treatment of thoracoabdominal stab injuries. Ulus Travma Acil Cerrahi Derg 2007;13:36-42. 4. Koda M, Ueki M, Maeda N, Murawaki Y. Diaphragmatic perforation and hernia after hepatic radiofrequency ablation. AJR Am J Roentgenol 2003;180:1561-2. 5. Shibuya A, Nakazawa T, Saigenji K, Furuta K, Matsunaga K. Diaphragmatic hernia after radiofrequency ablation therapy for hepatocellular carcinoma. AJR Am J Roentgenol 2006;186(5 Suppl):S241-3. 6. di Francesco F, di Sandro S, Doria C, Ramirez C, Iaria M, Navarro V, et al. Diaphragmatic hernia occurring 15 months after percutaneous radiofrequency ablation of a hepatocellular cancer. Am Surg 2008;74:129-32. 7. Nawa T, Mochizuki K, Yakushijin T, Hamano M, Itose I, Egawa S, et al. A patient who developed diaphragmatic hernia 20 months after percutaneous radiofrequency ablation for hepatocellular carcinoma. [Article in Japanese] Nihon Shokakibyo Gakkai Zasshi 2010;107:1167-74. [Abstract] 8. Yamagami T, Yoshimatsu R, Matsushima S, Tanaka O, Miura H, Nishimura T. Diaphragmatic hernia after radiofrequency ablation for hepatocellular carcinoma. Cardiovasc Intervent Radiol 2011;34 Suppl 2:S175-7. 9. Singh M, Singh G, Pandey A, Cha CH, Kulkarni S. Laparoscopic repair of iatrogenic diaphragmatic hernia following radiofrequency ablation for hepatocellular carcinoma. Hepatol Res 2011;41:1132-6. 10. Saber AA, Boros MJ. Chilaiditi’s syndrome: what should every surgeon

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Nakamura et al. Successful surgical rescue of delayed onset diaphragmatic hernia following RF ablation for hepatocellular carcinoma know? Am Surg 2005;71:261-3. 11. Moaven O, Hodin RA. Chilaiditi syndrome: a rare entity with important differential diagnoses. Gastroenterol Hepatol (N Y) 2012;8:276-8. 12. Urata K, Hashikura Y, Ikegami T, Terada M, Kawasaki S. Standard liver

volume in adults. Transplant Proc 2000;32:2093-4. 13. Kapoor BS, Hunter DW. Injection of subphrenic saline during radiofrequency ablation to minimize diaphragmatic injury. Cardiovasc Intervent Radiol 2003;26:302-4.

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Hepatoselüler karsinom için uygulanan radyofrekans ablasyon sonrası oluşan geç başlangıçlı diyafragma hernisinin başarılı cerrahi onarımı Dr. Tsukasa Nakamura,1 Dr. Koji Masuda,2 Dr. Rajveer Singh Thethi,3 Dr. Hirotaka Sako,2 Dr. Takaharu Yoh,4 Dr. Toshimasa Nakao,1 Dr. Norio Yoshimura1 Kyoto İdari Üniversitesi Tıp Fakültesi, Transplantasyon ve Rejeneratif Cerrahi Anabilim Dalı, Kyoto, Japonya; Omihachiman Toplum Sağlığı Merkezi, 2Cerrahi Kliniği, 4Gastroenteroloji ve Hepatoloji Kliniği, Shiga, Japonya; 3 St. James Üniversitesi Hastanesi, Safra Yolları ve Pankreas Cerrahisi Kliniği, Leeds, Birleşik Krallık 1

Cerrahi rezeksiyon için uygun olmadıkları düşünülen hepatoselüler karsinom (HSK) hastalarında temel tedavi olarak radyofrekans ablasyonun (RFA) rolü kanıtlanmıştır. Ancak bu işlem sonucunda geç dönemde diyafragma hernisi oluşabilmektedir. Literatürde bu komplikasyonu olan bu olgu dışında yalnızca yedi olgu bildirilmiştir. Bu işlemin popülaritesinde son zamanlarda oluşan artış göz önüne alınarak RFA’ya bağlı diyafragma hernisi insidansının kesinlikle artacağı öngörülebilir. Hastalarda bu halen nadir görülen komplikasyonla ilişkili sağkalım oranlarının iyileşmesine yol açabilen klinik farklındalığı artırdığı için bu olgu raporu yaşamsal önem taşımaktadır. Bu olgu, RFA prosedüründen 18 ay sonra geç başlangıçlı diyafragma hernisi ve boğulmuş fıtık belirtileriyle gelen, geçmişinde siroz ve HSK (IV. ve VIII. segmentler) öyküsü olan 81 yaşındaki Asyalı bir erkeğe ilişkindir. RFA uygulandığında diyafragmatik ve termal hasar riskini azaltmak için ekstra önlemler uygulamak önem taşır. Özellikle gastroenterologlar, cerrahlar, kaza cerrahisi ve acil cerrahi personeli tümüyle bu komplikasyonun farkında olmalı, daha önce RFA geçirmiş hastalar akut karın ağrısıyla geldiklerinde hızla tanı ve tedavi cihetine gitmelidir. Anahtar sözcükler: Diyafragma hernisi; geç başlangıçlı; hepatoselüler karsinom; radyofrekans ablasyon. Ulus Travma Acil Cerrahi Derg 2014;20(4):295-299

doi: 10.5505/tjtes.2014.03295

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CA S E R EP O RT

Surgical treatment of a Malgaigne fracture Sedat Dalbayrak, M.D.,1 Murat Ayten, M.D.,1 Fahir Özer, M.D.,2 Onur Yaman, M.D.3 1

Department of Neurosurgery, Neuro Spine Academy, Istanbul;

Department of Neurosurgery, Koc University Faculty of Medicine, Istanbul;

Department of Neurosurgery, Tepecik Training and Research Hospital, Izmir

ABSTRACT Sacral fractures are generally accompanied by pelvic ring fractures. They rarely develop in an isolated form. Sacroiliac dislocation without sacral fracture is extremely rare. We report a case with a sacroiliac dislocation without sacral fracture, which was treated surgically. Lumbopelvic stabilization was applied using iliac wing plates. The case was evaluated according to his clinical condition and visual analogue score (VAS), American Spinal Injury Association (ASIA) and Oswestry scales. Considering the role of the sacrum, which transmits the load of the entire spine to the pelvis, meticulous care must be given to ensure the mechanic stability of the spine when evaluating patients with sacral and pelvic fractures. Very serious spinopelvic instability is present in sacroiliac dislocations even in the absence of sacral fractures. Caudal migration of the sacrum together with the cranial migration of the iliac wings can cause serious pelvic imbalance and difficulties in walking and maintaining a standing position.Aggressive stabilization and fusion are required, and these must be performed in the early period. Key words: Iliac plate; malgaigne fracture; sacroiliac dissociation; spinopelvic instability; spinopelvic stabilization.

INTRODUCTION Unstable pelvic injuries characterized by the dissociation of the sacroiliac complex cause serious problems in the late period, including continuous pain and functional restrictions, in addition to the morbidity and mortality in the early period. [1,2] Ensuring anatomic reduction with stabilization and fusion is extremely important in sacroiliac dislocations. Since most of these injuries arise from high-energy traumas, other accompanying traumas must be investigated as well. A thorough physical examination including neurological and radiological examinations is required to determine the treatment. Studies have shown that functional outcomes are poor when sacroiliac dislocations are not reduced completely.[3] Malgaigne dislocation was described in the mid 1800s by a

Address for correspondence: Sedat Dalbayrak, M.D. Sabri Taşkın Cad., No: 18/1, Pendik, İstanbul, Turkey Tel: +90 216 - 375 10 53 E-mail: sedatdalbayrak@gmail.com Qucik Response Code

300

famous French anatomist and orthopedist. Malgaigne fracture consists of fracture of both pubic rami and posterior fracture of the sacroiliac complex. There is a vertically oriented combined fracture of the anterior and posterior pelvis. To date, many surgical techniques have been used in the fixation of the sacroiliac joint. It was not possible to ensure complete anatomic reduction with most of these techniques. Very important technical problems are encountered in the open procedures, particularly in delayed cases. Stabilization techniques involving lumbar vertebrae and iliac wings were developed over time to ensure complete anatomic reduction.[4-8] Van Savage and colleagues[2,9] were the first to use the Galveston technique for this purpose. Later, Käch and Trentz[2,10] proposed the distraction spondylodesis with L4-5 for the fixation of iliac bones. In 1998, Schildhauer et al.[2,11] reported the triangular osteosynthesis method, which included lumbopelvic distraction and transverse fixation of the sacral fracture. Abumi et al.[12] were the first investigators to use sacral pedicles and iliac wing for this purpose. They performed the fixation using Galveston technique between both pedicles of S1 and the iliac wings. When the anatomic importance of the sacrum and its role in mechanical stability as the bony ring of the pelvis are considered, giving meticulous care in the evaluation of patients with pelvic trauma is essential. Fixation with an iliac plate in Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Dalbayrak et al. Surgical treatment of a Malgaigne fracture

sacroiliac complex instability is a technique that has not been applied until now. This method ensures the reduction and stabilization in sacroiliac dislocations with or without sacral fractures. Further, there is the possibility of applying this stabilization method in other pathologies requiring sacroiliac fusion.[4] We report a patient with Malgaigne fracture that developed due to a fall from a height, without sacral fracture, who underwent surgery using iliac plates. The preoperative and postoperative American Spinal Injury Association (ASIA) neurologic status scale, visual analogue scale (VAS) and Oswestry scales and the clinical condition of the patient were evaluated. Pre- and postoperative changes in the computed tomography (CT), magnetic resonance imaging (MRI), and plain X-rays were examined. The patient was treated under elective conditions under general anesthesia in the prone position with the accompaniment of biplane scopy.

(a)

(b)

CASE REPORT A 38-year-old male experienced trauma due to a fall from a height (from a walnut tree). No fractures were present in the sacrum. There was dissociation fracture in the left iliac wing together with dissociation displacement in the sacroiliac joints bilaterally, and caudal sacral displacement together with sacroiliac dislocation (Figs. 1a, b). Linear fracture in the right acetabulum and compression fracture at T8 and T11 levels were determined. Thoracic vertebrae and left hemothorax were found as the accompanying traumatic pathologies (Fig. c). He was treated and followed with thoracic tube in the intensive care unit of the medical center to which he applied initially. He was referred to our center 45 days after the trauma. During that period, the patient underwent no operations, and was treated with medications and immobilization. Bilateral cutaneous traction was applied pre- and perioperatively. Preoperative VAS score of the case was 10 and Oswestry score was 94.

Surgical Technique Paravertebral muscles were dissected with a midline approach. Both iliac wings were clearly exposed together with area between L3 and the sacrum. Bilateral transpedicular screws were placed in the L3, L4, L5, and S1 vertebrae. Bilateral iliac wing plates were placed. Pedicular and iliac wing screws were fixed by placing rods. Complete reduction could not be achieved because of the delayed surgery. The combined spinopelvic stabilization was applied using a system we designed according to the anatomy of the iliac wings, in which the system sits on the iliac wings and is fixed to the iliac wings with nuts. The systems were connected to each other using dominos (Figs. 2-4). The duration of the operation was 245 minutes, and bleeding was determined as 1950 cc. Four units of erythrocyte suspension and two units of fresh frozen plasma were used. The case was mobilized 24 hours later and was discharged

(c)

Figure 1. (a) Sacroiliac dissociation with the caudal displacement of the sacrum and separation of the pubic symphysis. Fracture in the right acetabulum can be seen. (b) Axial CT image. Sacroiliac dislocation (a) without sacral fracture. The fracture line (b) in the iliac wing is seen on the left. (c) Accompanying pathologies: T8 compression fracture and right hemothorax.

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Figure 2. Perioperative view and postoperative radiograph after one year (right) showing the lumboiliac stabilization, performed using transpedicular screws between L3 and S1, iliac plates (1), iliac screws (2), and domino fixture connecting the rods to each other (3).

301

Dalbayrak et al. Surgical treatment of a Malgaigne fracture [14,15] Serious instability can be seen in patients with sacroiliac dislocation. Therefore, absolute fixation is required. In the articles about improvement in the neurological deficits in patients who do not undergo surgery, outcomes are not satisfactory.[4,8,11,13,16-20] Our opinion also favors surgery in the early periods in these cases. Inappropriate fusion developing in surgeries in the late period makes ensuring complete anatomic reduction during the operation more difficult. Purposes of the surgical sacral fixation include stabilizing the dislocation, improving the neurological condition and reducing all the disabilities. Surgical fixation in sacroiliac dislocations ensures the stability to allow early mobilization, preserving the local neurovascular structures and reducing the pelvic pain.[2-5,20]

Lumbopelvic fixation was designed to remove the effects of the instability pattern, which is frequently misunderstood. Stabilization methods include pelvic fixation, sacroiliac screws, direct sacral fixation, and lumbopelvic fixation to repair the stability of the lumbosacral joint.[2,4-7] Figure 3. Postoperative CT sections.

on postoperative day 5. No complications developed. Follow-ups were performed in postoperative months 2 and 6. In postoperative month 2, VAS score was 4 and the Oswestry score was 36, while in month 6, these values were 2 and 10, respectively. The patient had difficulty in walking during the initial mobilization related with the acetabulum; however, in the 6th month follow-up, it was observed that the gait of the patient was painless and regular.

In pediculoiliac fixation, reduction is done with the help of the rods between the screws, and full anatomic reduction is obtained with compression and distraction maneuvers possi-

DISCUSSION Sacral fractures constitute a complex group of injuries including the interruption of the pelvic ring, nerve root damage, cauda equina syndrome, and direct or indirect damage to the spinal segments. The rate of sacroiliac dislocation together with sacral fractures is extremely high.[3] Particularly according to the Dennis classification, the incidence of sacroiliac dislocation is high in zone I fractures.[13] Pure sacroiliac dislocation without sacral fracture is extremely rare. Vertical shear fractures, known as Malgaigne fractures, are the results of high-energy trauma. Sacroiliac dislocations are pathologies occurring as a result of axial loading, and almost all occur following falls from a height onto the feet. These injuries are characterized by rupture of the entire pelvic floor, including the posterior sacroiliac complex as well as sacrospinous and sacrotuberous ligaments. Malgaigne fracture consists of both anterior and posterior lesions: disruption of the symphysis or disruption of the inferior and superior pubic rami; disruption of all four rami; disruption of two rami plus pubic symphysis and posterior lesion; fracture of ileum; dislocation or fracture dislocation of the sacroiliac joint; or fracture of the 4th or 5th lumbar transverse process. Similar to the patient reported in this article, injuries to different regions, most frequently thoracic and lumbar vertebrae fractures and pelvic and abdominal organ injuries, accompany the sacroiliac dislocation. 302

Figure 4. Preoperative and postoperative pelvic X-ray. Partial closure of the dissociation at the pubic symphysis with compression of the iliac wings is shown.

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ble in every direction; compression between the fragments is also possible. In this method, the fixation points are the sacral pedicle and the cortices of the iliac bone. Using the area between the internal and external cortices of the ilium as the fixation site has been determined as the most stable method in the biomechanical studies performed in various lumbosacral fixation methods. In addition, it has been shown that the peel resistance increases when the sacral pedicle screws are located anteriorly and bicortically.[2,21,22] On the other hand, screws are generally placed in the same direction in sacroiliac transfixation or in anterior double plate applications. In this method, however, directions of both screws are different in each plane. All these features ensure important advantages, particularly for the primary stability.[2] Use of iliac screws in lumbosacral fixation is a modification of the Galveston method. Its modular characteristic eliminates the requirement of beveling the rod, and performing the construction according to the anatomy of the area becomes easier. Furthermore, applying the Galveston rod in a short level is rather difficult, and it is not possible to prevent the piston movement of the rod within the ilium, since the rod is straight. Another advantage of using the iliac screw is that it allows compression distraction in each plane.[2,9,23,24] Use of interlocking iliac wing plates in sacroiliac dislocations has gradually increased in recent years, presenting a new tool for stabilization. This technique is a rather effective method in the correction of translation deformities or residual angular deformities in transverse fractures.[4] Ensuring reduction in cases with sacroiliac dislocation in the early period is extremely important. Early surgical intervention allows the early mobilization of patients and more effective rehabilitation. Satisfactory improvement is also obtained in the neurologic deficits occurred during the trauma.[3-5,16,20,25] We believe that the interlocked iliac plate applied in this case represents a good alternative that can be used stand-alone in cases with serious instability requiring sacroiliac stabilization or in combination with other methods in view of its ease of use, its structure that complies with the iliac wing anatomy, and the very strong stabilization it ensures. In conclusion, the purpose of our study was to show that sacroiliac dislocation, which is generally seen simultaneously with sacral fractures and causes sacral instability, can also be seen without sacral fracture, though very rare. Early operation in patients with sacroiliac instability is extremely important to ensure early mobilization. Although application of an iliac wing in sacroiliac fixation is a new method, it is very effective in ensuring stabilization. Conflict of interest: None declared.

REFERENCES 1. Dujardin FH, Hossenbaccus M, Duparc F, Biga N, Thomine JM. Long-

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term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma 1998;12:145-51. 2. Sar C. S1-pediculoiliac fixation in sacroliac joint complex instabilities. [Article in Turkish] Acta Orthop Traumatol Turc 2001;35:175-8. 3. Robles LA, Plantillas E. An unusual transverse sacral fracture treated with early decompression. Case report. J Neurosurg Spine 2006;5:546-9. 4. Dalbayrak S, Yilmaz M, Kaner T, Gokdag M, Yilmaz T, Sasani M, et al. Lumbosacral stabilization using iliac wings: a new surgical technique. Spine (Phila Pa 1976) 2011;36:673-7. 5. Keel MJ, Benneker LM, Siebenrock KA, Bastian JD. Less invasive lumbopelvic stabilization of posterior pelvic ring instability: technique and preliminary results. J Trauma 2011;71:62-70. 6. Lindahl J. Lumbopelvic fxation for sacral fracture-dislocations. Suomen Ortopedia ja Traumatologia 2009;32:125-7. 7. Lykomitros VA, Papavasiliou KA, Alzeer ZM, Sayegh FE, Kirkos JM, Kapetanos GA. Management of traumatic sacral fractures: a retrospective case-series study and review of the literature. Injury 2010;4:266-72. 8. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt ML Jr, Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma 2006;20:44757. 9. Van Savage JG, Dahners LE, Renner JB, Baker CC. Fracture-dislocation of the lumbosacral spine: case report and review of the literature. J Trauma 1992;33:779-84. 10. Käch K, Trentz O. Distraction spondylodesis of the sacrum in “vertical shear lesions” of the pelvis. [Article in German] Unfallchirurg 1994;97:28-38. [Abstract] 11. Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weightbearing. J Orthop Trauma 1998;12:307-14. 12. Abumi K, Saita M, Iida T, Kaneda K. Reduction and fixation of sacroiliac joint dislocation by the combined use of S1 pedicle screws and the galveston technique. Spine (Phila Pa 1976) 2000;25:1977-83. 13. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;227:6781. 14. Mehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. J Am Acad Orthop Surg 2006;14:656-65. 15. Schmidek HH, Smith DA, Kristiansen TK. Sacral fractures. Neurosurgery 1984;15:735-46. 16. Bodkin PA, Choksey MS. Management of a sacral fracture with neurological injury. J Orthop Sci 2006;11:524-8. 17. Bonin JG. Sacral fractures and injuries to the cauda equina. J Bone Joint Surg Br 1945;27:113-27. 18. Routt ML Jr, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am 1997;28:369-88. 19. Yi C, Hak DJ. Traumatic spinopelvic dissociation or U-shaped sacral fracture: a review of the literature. Injury 2012;43:402-8. 20. Zelle BA, Gruen GS, Hunt T, Speth SR. Sacral fractures with neurological injury: is early decompression beneficial? Int Orthop 2004;28:244-51. 21. McCord DH, Cunningham BW, Shono Y, Myers JJ, McAfee PC. Biomechanical analysis of lumbosacral fixation. Spine (Phila Pa 1976) 1992;17(8 Suppl):S235-43. 22. Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res 1986;203:99-112. 23. Gokaslan ZL, Romsdahl MM, Kroll SS, Walsh GL, Gillis TA, Wildrick DM, et al. Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms. Technical note. J Neurosurg 1997;87:781-7. 24. Jackson RJ, Gokaslan ZL. Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg 2000;92(1 Suppl):61-70. 25. Kınık H. Pelvis kırıkları ve tedavisi. TOTBİD (Türk Ortopedi ve Travmatoloji Dergisi) 2008;7:40-50.

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Malgaigne kırığı’nın cerrahi tedavisi Dr. Sedat Dalbayrak,1 Dr. Murat Ayten,1 Dr. Fahir Özer,2 Dr. Onur Yaman3 1 2 3

Nöro Spinal Akademi, Nöroşirürji Bölümü, İstanbul; Koç Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, İstanbul; Tepecik Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İzmir

Sakral kırıklar pelvik halkanın dağılması, sinir kök hasarı, kauda ekuina sendromuna neden olan direkt ve indirekt spinal segment hasarına neden olan karmaşık yaralanmalardır. Malgaigne kırıkları pubis rami kırığı ya da simfisis pubisin ayrılması ile birlikte sakroiliak kompleksin kırığı ile birliktedir. Pelvisin ön arka vertikal kırığıdır. Bu yazıda sakroiliak ayrılma nedeniyle sakral kırığı ve instabilitesi olan Molgaigne kırığı olan hastanın cerrahi tedavisi sunuldu. Yüksekten düşme nedeniyle Malgaigne kırığı olan hasta iliak plaklarla cerrahi olarak tedavi edildi. Cerrahi öncesi ve sonrası nörolojik durumu ASIA skorlaması, ağrı düzeyi VAS ve Oswestry skorlaması and klinik durumu tespit edildi. Cerrahi öncesi ve sonrası durumları BT, MR ve direkt grafi ile incelendi. Gecikmiş cerrahi nedeniyle redüksiyon tam olarak sağlanamadı. Spinopelvik stabilizasyon iliak kanatlara uygun olarak dizayn edilmiş iliak kanat plakları ile ameliyat edildi. L3, L4, L5 ve S1 iki taraflı transpediküler vidalar ile iliak kanat plakları dominolar aracılığı ile rodlarla birleştirildi. İliak kanatlar için geliştirdiğimiz iliak kanat plakları sakroiliak instabilitesi olan sakroiliak stabilizasyon gereken hastalarda tek başına ya da diğer yöntemlerle kullanılabilecek uygulanması kolay ve güçlü stabilizasyon sağlayan alternatif bir yöntemdir. İliak kanat plakları sakroiliak fiksasyon için kullanılabilecek etkili yeni bir yöntemdir. Anahtar sözcükler: İliak plak; Malgaigne kırığı; sakroiliak ayrılma; spinopelvik instabilite; spinopelvik stabilizasyon. Ulus Travma Acil Cerrahi Derg 2014;20(4):300-304

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Thyroid storm due to head injury Gülşah Yılmaz Karaören, M.D.,1 Omer Torun Sahin, M.D.,1 Zeynel Abidin Erbesler, M.D.,2 Nurten Bakan, M.D.1 1

Department of Anaesthesiology and Reanimation, Istanbul Umraniye Training and Research Hospital, Istanbul;

Department of Anaesthesiology and Reanimation Van Ercis State Hospital, Van

ABSTRACT In this case report, we would like to present a 36-year-old male patient injured in a street fight without any disease previously known, who was accepted to our intensive care unit with the preliminary diagnoses of minimal cerebral contusion and aspiration pneumonia however by the physical examination, clinical and laboratory findings, was diagnosed as thyroid storm due to trauma. In the current literature, only a few cases reported showing thyroid storm-induced by trauma, and we would like to present the clinical features and management of this life-threatening endocrinological emergency. Key words: Aspiration; brain contusion; complications-trauma; hyperthyroidism; pneumonia; thyrotoxic storm.

INTRODUCTION

CASE REPORT

Thyroid storm is a rare, but life-threatening endocrinological emergency characterized by severe clinical manifestations of thyrotoxicosis. Incidence of this hyperthyroidism state is about 1-2%[1] with high mortality rates, of 20-30%.[2] There is consensus among authors that the conversion from thyrotoxicosis to thyroid storm is caused by a precipitating event. Although rare, trauma is one such trigger.[2]

A 36-year-old male injured in a street fight presented at the emergency department. His relatives said that he was healthy before his admission. He was not taking any medication, had no known allergy, no family history of inherited disease, and no alcohol or recreational drug use.

Thyroid storm symptoms and signs may vary and are mainly non-specific due to the widespread effects of thyroid hormones.[3] For the limitation of mortality and morbidity, early diagnosis and treatment are essential. In this report, we describe the importance of neck examination with palpation of the thyroid gland in a 36-year-old trauma patient.

Address for correspondence: Gülşah Yılmaz Karaören, M.D. Ümraniye Eğitim ve Araştırma Hastanesi, İstanbul, Turkey Tel: +90 216 - 632 18 18 E-mail: drgyilmaz@yahoo.com Qucik Response Code

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His Glasgow coma score (GCS) remained at 13 in the resuscitation room, and he was irritable. On a primary survey, he was tachypneic (40/min) tachycardic (120 bpm), and his blood pressure (BP) was 160/90 mmHg. His pupils were isochoric and reactive to light. As the GCS decreased from 13 to 11, a head injury was suspected. Tomographic scanning of the thorax, head, and cervical spine was performed, and a minor left temporal contusion was determined. The patient was admitted to the neurosurgery department for further follow-up.After 10 hours, the patient became unresponsive to verbal and tactile stimuli, and GCS decreased to 5. The pupils were normal and reactive, and he had no lateralization signs. Heart rate (HR) was 130 bpm, BP was 170/90 mmHg, and core temperature (CT) was 38.7°C. Respiratory rate was 40/min and breath sounds were noisy with inspiratory rales. Blood-gases showed pH 7.3 mmHg, pO2 77 mmHg, and pCO2 31 mmHg.The patient was intubated and taken to the radiology department again to see if there had been a recently developed hemorrhage or shift. No difference was observed between the first and the control cranial tomography scans. The neurosurgery team was of the opinion that the small contusion was not sufficient to explain the low GCS level. 305

Yılmaz Karaören et al. Thyroid storm due to head injury

Finally, he was transported to the intensive care unit (ICU) with a diagnosis of minimal cerebral contusion and pneumonia due to gastric content aspiration. In the ICU, oxygen saturation was 90% during mechanical ventilation (continuous positive airway pressure [CPAP]/ pressure support ventilation [PSV], positive end expiratory pressure [PEEP] 8 mmHg pressure support [PS] 15 mmHg) with the fraction of inspired oxygen of 0.5. He was sedated with midazolam 5 mg/kg and remifentanil 0.25 µg/kg infusions.

was 170/74 mmHg. Diffuse erythema on the face and chest was seen on skin examination. His CT was 39°C. Ceftriaxone was administered after blood and tracheal aspiration cultures were obtained. Laboratory evaluation determined normal electrolyte, hepatic, and renal panels. White blood cell was 7500 cells/mL, hemoglobin, 11.4 g/dL, and platelet, 140,000 cells/mL. The arterial lactate level was 10 mg/dL (normal, 5-14 mg/dL). Urine analysis showed no abnormality.

The pupils were observed to be round and reactive, and the neck was supple. He had a minimally enlarged thyroid gland with no bruit or evident nodule. The trachea was in the midline and auscultation of the chest demonstrated crackles. Cardiac examination revealed tachycardia (140 bpm) and BP Table 1. Scoring system to diagnose thyroid storm* Diagnostic parameters

While the thyroid panel is not routinely evaluated in our ICU, we decided to obtain one because of the enlarged thyroid gland. After 12 hours in the ICU, the patient remained critically ill with CT of 40°C despite IV paracetamol. HR was 140 bpm and BP was 180/90 mmHg. After 24 hours, the thyroid function tests were reported. The thyroid-stimulating hormone (TSH) was 0.0001 uIU/mL, FT3, 11.29 (normal, 1.71-3.71) pg/mL, and FT4, 3.3 (normal, 0.7-1.49) pg/mL.[1] Point

Thermoregulatory dysfunction, °F 99.0-99.9

100.0-100.9

101.0-101.9

102.0-102.9

103.0-103.9

≥104.0

Central nervous system dysfunction

Mild (agitation)

Moderate (delirium, psychosis, extreme lethargy)

Severe (seizures, coma)

Gastrointestinal dysfunction

Moderate (diarrhea, nausea/vomiting, abdominal pain)

Severe (unexplained jaundice)

Cardiovascular dysfunction: tachycardia, beats/min 90-109

110-119

120-139

≥140

Cardiovascular dysfunction: congestive heart failure

Mild (pedal edema)

Moderate (bibasilar rales)

Severe (pulmonary edema)

Cardiovascular dysfunction: atrial fibrillation Present

Precipitating event

Present

A score ≥45 is highly suggestive of thyroid storm. A score of 25 to 44 supports the diagnosis of thyroid storm. A score <25 is unlikely to be thyroid storm. Adapted from Burch and Wartofsky.[4]

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A diagnosis of thyroid storm due to head injury was considered. According to the Burch and Wartofsky scoring system, a score of 45 or more is highly suggestive of thyroid storm; thus, the patient met the criteria with a score of 70 (Table 1).[4] Therapy was started of propylthiouracil (PTU) 100 mg/4 hour, propranolol 40 mg/8 hour, and methylprednisolone 1 mg/kg and esmolol 50-100 µg/kg/min infusion. No iodine or hydrocortisone preparation was available. There was a significant improvement in his hemodynamics after the 24th hour of medication. Large boluses of fluid were administered due to fever and sweating. CVP was 8-10 mmHg. On the 3rd day of ICU admission, FT3 level gradually decreased to 7.2 pg/mL and FT4 level was 2.2 pg/mL; on the 9th day, FT3 was 3.4 pg/mL, FT4 was 1.85 pg/mL, and TSH was 0.0004 uIU/mL. The patient was extubated on the 4th day. There was a gradual improvement in mental status from the minor contusion. He was advised to follow routine endocrinology controls and was discharged to the neurosurgery department on the 9th day of ICU admission.

DISCUSSION Thyroid storm is the most serious complication of hyperthyroid state and even with treatment, has a high risk of mortality.[3] There are few case reports in literature, which mention trauma as a precipitating event of thyroid storm.[5] The incidence is <10% of the patients interned to hospital for thyrotoxicosis, and it is generally related to a precipitating event, such as comorbid conditions, infecUlus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

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tion, thyroid or non-thyroidal surgery, pulmonary embolism, pre-eclampsia, emotional stress, or withdrawal of anti-thyroid medications.[6] The progression of thyrotoxicosis to thyroid storm is difficult to predict. There is no pathognomonic constellation of signs and symptoms as thyroid storm is so variable in terms of presentation. In some cases, hyperglycemia, leukocytosis, elevated plasma calcium levels and abnormal liver function tests may be seen. [5] The diagnosis of a thyroid storm is based upon clinical findings.[1] Patients with thyroid storm can manifest fever, nausea, vomiting, diarrhea, and jaundice (gastrointestinal or hepatic dysfunction), nervous system disorders, arrhythmia, and other cardiovascular abnormalities.[2] The patient history and physical examination assist in the differential diagnosis. The physical findings of an enlarged thyroid gland, tachycardia, a widened pulse pressure, fever, tachypnea, lid lag, hand tremor, warm and moist skin, depressed mental status and ophthalmopathy (in the presence of Graves’ disease) are all consistent with thyroid storm. Although TSH is generally undetectable, a low thyrotropin (TSH) level also supports the diagnosis.[3] In the case presented here, it seems that a pre-existing and untreated abnormality of the thyroid gland was responsible for the clinical picture. On the basis of this constellation of findings, the most likely diagnosis was thyroid storm, precipitated by trauma, in a patient with pre-existing hyperthyroidism. Treatment includes regulation of the hyperthyroid state with anti-thyroid medications. In addition to thioamides, iodine may be administered to decrease thyroid hormone synthesis. It is essential to restore homoeostasis with IV hydration, and betaadrenergic blockers may be required to control cardiovascular manifestations. Glucocorticoids can be used to inhibit the conversion of thyroxine (T4) to triiodothyronine (T3).[7] PTU decreases new hormone production and peripheral de-iodination of T4 to T3. It should be noted that PTU is no longer recommended as a first-line agent in the management of Graves’ disease, due to safety concerns related to liver failure.[8] In the current case, the absence of a suitable iodine preparation forced us to use PTU instead, and we followed the hepatic panel carefully.

Vasomotor abnormalities can be aggravated by fever and should be treated with antipyretics. However, aspirin should be avoided as it induces decreased binding of T3 and T4 to thyroxine-binding globulin.[3] Treatment with paracetamol, as an alternative drug, can be useful without side-effects. When clinical deterioration occurs despite aggressive medical therapy, thyroid hormone can be removed directly by plasmapheresis, charcoal, resin hemoperfusion, or plasma exchange. [9] In the current case, these aggressive treatment methods were not required. This case demonstrated the importance of a neck examination with palpation of the thyroid gland. Early recognition with a full clinical history and physical examination and aggressive treatment are fundamental in limiting the morbidity and mortality associated with this endocrine emergency. Written informed consent was obtained from a family member of the patient. Conflict of interest: None declared.

REFERENCES 1. Karger S, Führer D. Thyroid storm--thyrotoxic crisis: an update. [Article in German] Dtsch Med Wochenschr 2008;133:479-84. [Abstract] 2. Vora NM, Fedok F, Stack BC Jr. Report of a rare case of trauma-induced thyroid storm. Ear Nose Throat J 2002;81:570-4. 3. Graham BB, Burnham EL, Janssen JS, Janssen WJ. Dyspnea, chest pain, and altered mental status in a 33-year-old carpenter. Chest 2008;134:1074-9. 4. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77. 5. Wilkinson JN. Thyroid storm in a polytrauma patient. Anaesthesia 2008;63:1001-5. 6. Malchiodi L. Thyroid storm: recognizing the signs and symptoms of this life-threatening complication. American Journal of Nursing 2002;102:33-5. 7. Birrell G, Cheetham T. Juvenile thyrotoxicosis; can we do better? Arch Dis Child 2004;89:745-50. 8. Rivkees SA, Mattison DR. Ending propylthiouracil-induced liver failure in children. N Engl J Med 2009;360:1574-5. 9. Ashkar FS, Katims RB, Smoak WM 3rd, Gilson AJ. Thyroid storm treatment with blood exchange and plasmapheresis. JAMA 1970;214:1275-9.

OLGU SUNUMU - ÖZET

Kafa travmasına bağlı tiroit fırtınası Dr. Gülşah Yılmaz Karaören,1 Dr. Omer Torun Sahin,1 Dr. Zeynel Abidin Erbesler,2 Dr. Nurten Bakan1 1 2

İstanbul Ümraniye Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, İstanbul; Van Ercis Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Van

Bu yazıda, önceden bilinen bir hastalığı olmayan, sokak kavgasında yaralanma sonrasında yoğun bakıma minimal serebral kontüzyon ve aspirasyon pnömonisi ön tanıları ile alınan, ancak fiziksel inceleme ve labaratuvar bulguları sonucunda travmaya bağlı gelişen tiroit fırtınası tanısı konulan 36 yaşındaki erkek hasta sunuldu. Mevcut literatürde travmanın indüklediği tiroit fırtınası sadece birkaç olguda bildirilmiştir. Biz de, bu hayatı tehdit eden endokrinolojik acilin özelliklerini ve anestezik yönetimini sunmayı amaçladık. Anahtar sözcükler: Aspirasyon; beyin kontüzyon; komplikasyonlar-travma; hipertiroidizm; pnömoni; tirotoksik fırtına. Ulus Travma Acil Cerrahi Derg 2014;20(4):305-307

doi: 10.5505/tjtes.2014.99248

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Swallowed a needle stuck in heart Mustafa Yolcu, M.D.,1 Ahmey Aydın, M.D.,2 Ali Fuat Korkmaz, M.D.,1 Özgür Dağ, M.D.,2 Emrah İpek, M.D.,1 Bilgehan Erkut, M.D.2 1

Department of Cardiology, Erzurum Region Training and Research Hospital, Erzurum;

Department of Cardiovascular Surgery, Erzurum Region Training and Research Hospital, Erzurum

ABSTRACT Cardiac tamponade (CT) is a clinical entity characterized by hemodynamic insufficiency resulting from increased intrapericardial pressure due to accumulation of contents such as serous fluid, blood, and pus. CT is a treatable cause of cardiogenic shock, which can be fatal unless diagnosed promptly. Dyspnea, chest pain, hypotension, tachycardia, pulsus paradoxus, raised jugular venous pressure, muffled heart sounds, decreased electrocardiographic voltage, and enlarged cardiac silhouette on chest X-ray are the major clinical signs in CT. Idiopathic or viral pericardititis, iatrogenic trauma during percutaneous coronary interventions or coronary artery bypass grafting, external trauma, malignancies, acute or chronic kidney disease, collagen vascular diseases, tuberculosis, radiation on the chest wall, hypothyroidism and aortic dissection are the etiologic factors. Herein, we present a case of surgically treated CT, which was diagnosed in the third day of ingestion of a sewing needle. Key words: Cardiac tamponade; esophagus; needle.

INTRODUCTION Cardiac tamponade (CT) is a clinical entity characterized by hemodynamic insufficiency resulting from increased intrapericardial pressure due to accumulation of contents such as serous fluid, blood, and pus.[1] Idiopathic or viral pericardititis, iatrogenic trauma during percutaneous coronary interventions or coronary artery bypass grafting (CABG), external trauma, malignancies, acute or chronic kidney disease, collagen vascular diseases, tuberculosis, radiation on the chest wall, hypothyroidism, and aortic dissection are the etiologic factors.[2] Herein, we present a case of surgically treated CT, which was diagnosed in the third day of ingestion of a sewing needle.

CASE REPORT A 35-year-old male patient was admitted to our emergency clinic with the complaints of abdominal pain, progressive dysAddress for correspondence: Mustafa Yolcu, M.D. Erzurum Bölge Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, Çat Yolu, Erzurum, Turkey Tel: +90 442 - 232 55 55 E-mail: yolcudoctor@gmail.com Qucik Response Code

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pnea and palpitations started after ingestion of a meal 3 days ago. In his physical examination, the arterial blood pressure was 80/40 mmHg, and he was tachycardic and tachypneic. Cardiac auscultation revealed muffled heart sounds and there were not any murmurs or pathologic sounds. There were jugular venous distension and hepatomegaly. The electrocardiography (ECG) revealed sinus tachycardia and low QRS voltage. In chest X-ray, the cardiothoracic ratio was increased, and there was a metallic needle density over the diaphragm (Fig. 1a). In transthoracic echocardiography, a pericardial effusion with 3 cm width was detected surrounding the entire heart resulting in diastolic collapse of the right ventricle. The patient was then examined under scopy, and a sewing needle with 4 cm length was shown to have a synchronized motion with the heart. A thorax computer tomography was taken, and the needle was demonstrated to have one tip in the distal esophagus and the other tip in the pericardium next to the left atrium (Fig. 1b). An emergency surgery was performed. After median sternotomy, the pericardium was opened vertically, and cardiac decompression was achieved. The fibrin and hematoma on the heart was cleaned. When the heart was exposed and lifted, a 4-cm long sewing needle which had its 2 cm portion in the pericardium was extracted (Fig. 1c and d). The thorax was closed after bleeding control. Then the patient was discharged in the 3rd day without any complications. Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

Yolcu et al. Swallowed a needle stuck in heart

(a)

(b)

(c)

(d)

Figure 1. (a) Appearance of the needle on chest. (b) Computer tomography image of the needle. (c) The needle during operation. (d) The needle after operation.

DISCUSSION CT causes hemodynamic insufficiency due to compression of heart chambers by a pericardial fluid leading increased pericardial pressure.[1] CT is a treatable cause of cardiogenic shock which can be fatal unless diagnosed promptly.[1] Dyspnea, chest pain, hypotension, tachycardia, pulsus paradoxus, raised jugular venous pressure, muffled heart sounds, decreased ECG voltage, and enlarged cardiac silhouette on chest X-ray are the major clinical signs in CT.[3] The percutaneous pericardiosynthesis, balloon pericardiotomy or surgical drainage are the treatment options depending on the clinical presentation.[3-5] Depending on the rate of effusion formation, CT can have rapid or slow progression. This situation shows that tamponade is related mostly to the rate of accumulation of fluid in the pericardium rather than the quantity of effusion. The mean right atrial filling pressure formed by normal systemic venous return is 6-8 mmHg.[6] During CT the rapid accumulation of fluid in non-elastic pericardial cavity prevents the filling of the right atrium.[6] The intrapericardial pressure first overcomes the right atrial pressure then the right ventricular pressure was overcome.[6] The cardiac output falls depending on increased intrapericardial pressure over right Ulus Travma Acil Cerrahi Derg, July 2014, Vol. 20, No. 4

heart pressures, which then causes clinical CT.[6] Depending on the rate of effusion formation, CT can have rapid or slow progression. This situation shows that tamponade is related mostly to the rate of accumulation of fluid in the pericardium rather than the quantity of effusion. The right heart catheterization is diagnostic, but now-a-days transthorasic echocardiography takes the role since it is noninvasive, rapid, and reliable.[7] The main echocardiographic findings are compression of right heart chambers, dilatation of the inferior vena cava without respiratory variation of its diameter and increased respiratory variation of intracardiac Doppler velocities.[1,2] Besides its diagnostic importance, echocardiography is a useful guide during pericardiosynthesis.[1,2] Echo-guided pericardiosynthesis is a reliable, rapid and well-tolerated procedure. A study in Mayo Clinic revealed that it has 97% success and 4.7% total complication rate.[4] However, Gumrukcuoglu et al. reported that it has 97% success and 10% total complication rate.[1] In 1826, Larrey defined drainage procedure for pericardial effusion through sub-xyphoidal region.[8] Emergency pericardiosynthesis can relieve CT, but surgical drainage may be necessary, especially in tamponades after trauma, CABG and percutaneous coronary interventions.[8] Surgical sub309

Yolcu et al. Swallowed a needle stuck in heart

xyphoidal window is a simple and reliable procedure and has lesser mortality, complication, and recurrence rates.[8] In foreign body or trauma induced tamponades, as in our case, a sternotomy is necessary most of the time in order to evaluate and treat the cardiac injury properly. Surgical approach should be considered, especially in purulent, recurrent, and malignant effusions and if a biopsy is needed for the diagnosis.[1] In a study in Mayo Clinic, 88 patients who experienced CT due to catheter-based procedures and underwent pericardiosynthesis with guidance of echocardiography were studied retrospectively and cardiac surgery after pericardiosynthesis was shown to be 18%.[4] Olivotti et al.[8] reported an ingested metallic wire, which caused CT passing into the pericardium through esophagus. A few CT cases after ingestion of a metallic wire or needle which then passed through diaphragm, was previously reported also. In a few case reports, it was stated that a Kirschner wire left its location and reached the heart via arterial route leading CT. Gevaert et al. reported a case in which a 3-cm long sharp piece of crab caused CT passing through the diaphragm. Herein, we present a CT case of a sewing needle, which was ingested and passed into the pericardium through the esophagus and lead tamponade by disruption of the right atrium. As a result, pericardial effusion and tamponade have a lot of

reasons. It must be kept in mind that ingested metallic wires or needles can pass into the pericardium through esophagus or diaphragm and lead tamponade. Conflict of interest: None declared.

REFERENCES 1. Gumrukcuoglu HA, Odabasi D, Akdag S, Ekim H. Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery-A Report of 100 Patients. Cardiol Res Pract 2011;2011:197838. 2. Sagristà-Sauleda J, Mercé AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol 2011;3:135-43. 3. Seferović PM, Ristić AD, Imazio M, Maksimović R, Simeunović D, Trinchero R, et al. Management strategies in pericardial emergencies. Herz 2006;31:891-900. 4. Phadke G, Whaley-Connell A, Dalal P, Markley J, Rich A. Acute Cardiac Tamponade: An Unusual Cause of Acute Renal Failure. Cardiorenal Med 2012;2:83-86. 5. Spodick DH. Acute cardiac tamponade. N Engl J Med 2003;349:684-90. 6. Cuculi F, Newton JD, Banning AP, Prendergast BD. Resistant pericardial tamponade. Circulation 2011;123:566-7. 7. Tsang TS, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol 1998;32:1345-50. 8. Olivotti L, Succio G, Moshiri S, Nicolino A, Gravano M, Serafini G, et al. Cardiac tamponade caused by a swallowed metallic wire. J Am Coll Cardiol 2010;56:e27.

OLGU SUNUMU - ÖZET

Yutulup kalbe saplanmış iğne Dr. Mustafa Yolcu,1 Dr. Ahmey Aydın,2 Dr. Ali Fuat Korkmaz,1 Dr. Özgür Dağ,2 Dr. Emrah İpek,1 Dr. Bilgehan Erkut2 1 2

Erzurum Bölge Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, Erzurum; Erzurum Bölge Eğitim ve Araştırma Hastanesi, Kardiyovasküler Cerrahi Kliniği, Erzurum

Kardiyak tamponat (KT) seröz sıvı, kan ve püğ gibi içeriklerin birikiminin yol açtığı intraperikardiyal basınç artışı sonucu hemodinamik yetersizlikle karakterize klinik durumdur. KT acil olarak tedavi edilmediğinde ölümcül olabilen kardiyojenik şokun tedavi edilebilir bir nedenidir. Nefes darlığı, göğüs ağrısı, hipotansiyon, taşikardi, pulsus paradoksus, artmış juguler venöz basınç, derinden gelen kalp sesi, azalmış elektrokardiyografik voltaj ve akciğer grafisinde genişlemiş kardiyak silüet KT’nin majör bulgularıdır. İdiyopatik ya da viral perikardit, koroner baypas ya da perkütan koroner girişim sırasında oluşabilen iyatrojenik travma, eksternal travma, kanserler, akut ya da kronik böbrek hastalığı, kollojen doku hastalıkları, tüberküloz, göğüs duvarına radyasyon, hipotiroidi ve aort diseksiyonu etiyolojik faktörlerdir. Biz burada dikiş iğnesinin yutulmasının üçüncü gününde tanı konulan ve cerrahi olarak tedavi edilen KT olgusunu sunduk. Anahtar sözcükler: İğne; kardiyak tamponat; özofagus. Ulus Travma Acil Cerrahi Derg 2014;20(4):308-310

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doi: 10.5505/tjtes.2014.30049

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