(RSS) Karim's Weblog
Random snippets and thoughts - hopefully mostly trauma related!
- Karim Brohi
- trauma.org; London
Karim's Weblog
Random snippets and thoughts - hopefully mostly trauma related!
Authors:
- Karim Brohi
- trauma.org; London
Recent Posts:
So, just in time for this year's London Trauma Conference, we've uploaded the presentations from the 'Trauma Massive Transfusion & Coagulopathy State of the Art Symposium' held at the London Trauma Conference in 2008. This set of lectures presents an overview of the current state of knowledge in the exploding field of Trauma Induced Coagulopathy (TIC) and transfusion practice. At this year's conference we'll be holding a complementary Scientific Symposium on Trauma Haemostasis & Transfusion. The programme is just being finalized and will be available in the next few days. Meanwhile, enjoy the presentations from last year - and TRAUMA.ORG's new video channel on Vimeo.
As some of you have surmised this is a typical (if rare) picture of cardiac herniation. This is not dextrocardia/situs as the anatomy of the aortic arch is normal. Also the high vasopressor requirement suggests that this is not normal for the patient! Similarly the picture is not typical of other postulated causes such as tension pneumothorax, tension pneumomediastinum, tension pneumopericardium etc. The patient was taken to the operating room. A left anterolateral thoractomy incision was performed and the pericardium opened. The pericardium was empty which confirmed the diagnosis. The incision was extended into a full clamshell incision.
The heart was twisted on the SVC/IVC axis and was oedematous and engorged. The right phrenic nerve was intact but torn free from the pericardium. The preidcardial tear was widened and the heart relocated, with a good return in blood pressure and a decrease in vasopressor requirements.
The right lateral tear in the pericardium was closed to avoid the heart re-twisting into the right chest. The surgical pericardial incision was left widely open as the heart was too engorged for it to be closed. The clamshell incision was closed and the patient taken to the intensive care unit for further management.
Cardiac herniation is rare but is a correctable cause of traumatic arrest or profound hypotension and must be considered. There are several cases in the literature and two case reviews [PMIDs 9253902 and 16096553]. The Chest X-ray and CT findings of a right-sided herniation are clear here, although many are left-sided and the chest X-ray may be normal.
So this patient came with a CT scan.
Those of you thinking dextrocardia - does this help you at all? What exactly is going on here??
Very interesting case a couple of weeks ago. This patient suffered significant blunt force trauma to the chest and was secondarily transferred to us for management of a thoracic spinal fracture-dislocation with associated spinal cord injury. He arrived 12 hours or so following the injury on very large doses on inotropes to support his blood pressure. Here's his chest X-ray.
Something's not quite right here. Is there a clear diagnosis? What's your next move? Let's have some ideas in the comments...
Today we've had a major overhaul of TRAUMA.ORG's services. Most of these are back-end improvements to community features. Users should now find it a lot easier to contribute images and cases, and institution to post fellowships and student elective opportunities.
As part of our commitment to supporting and developing the global trauma community, this update of TRAUMA.ORG sees the addition of community blogs (including this one!). The first one to role out is a trauma research blog. New or interesting research will be highlighted here with a short editorial comment. You're all welcome to discuss the article in the comments, and of course recommend articles yourselves. Maybe it should be completely open for all to submit articles to? We'll see how it develops!
I thought we should have a momentous first post in the research blog. So what is the most important trauma paper ever written? There were a few candidates, but I finally settled on one that I think changed the way the world views trauma. Which one did I choose?
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