No abstract

Crush injuries can occur in large numbers following natural disasters or acts of war and terrorism. They can also occur sporadically after industrial accidents or following periods of unconsciousness from drug intoxication, anaesthesia, trauma or cerebral events. A common pathophysiological pathway has been elucidated over the last century describing traumatic rhabdomyolysis leading to myoglobinuric acute renal failure and a systemic ‘crush syndrome’ affecting many organ systems. If left unrecognised or untreated, then mortality rates are high. If treatment is commenced early and the systemic effects are minimised then patients are often faced with significant morbidity from the crushed limbs themselves. We have performed a thorough review of the English language literature from 1940 to 2009 investigating crush injuries and crush syndrome and present a comprehensive, two-part summary. Part 1: The systemic injury: In this part we concentrate on the systemic crush syndrome. We determine the pathophysiology, clinical and prognostic indicators and treatment options such as forced alkaline diuresis, mannitol therapy, dialysis and haemofiltration. We discuss more controversial treatment options such as allopurinol, potassium binders, calcium therapy and other diuretics. We also discuss the specific management issues of the secondary ‘renal disaster’ that can occur following earthquakes and other mass disasters. Part 2: The local injury: Here we look in more detail at the pathophysiology of skeletal muscle damage following crush injuries and discuss how to minimise morbidity by salvaging limb function. In particular we discuss the controversies surrounding fasciotomy of crushed limbs and compare surgical management with conservative techniques such as mannitol therapy, hyperbaric oxygen therapy, topical negative pressure therapy and a novel topical treatment called gastric pentadecapeptide BPC 157.

Crush injuries can occur in considerable numbers following natural disasters or acts of war and terrorism. They can also occur sporadically after industrial accidents or following periods of unconsciousness from drug intoxication, anaesthesia, trauma or cerebral events. A common pathophysiological pathway has been elucidated over the last century describing traumatic rhabdomyolysis leading to myoglobinuric acute renal failure and a systemic ‘crush syndrome’ affecting many organ systems. If left unrecognised or untreated then mortality rates are high. If treatment is commenced early and the systemic effects are minimised then patients are often faced with significant morbidity from the crushed limbs themselves. We have performed a thorough review of the English language literature from 1940—2009 investigating crush injuries and crush syndrome and present a comprehensive, two-part summary. Part 1: The systemic injury, we concentrate on the systemic crush syndrome. We determine the pathophysiology, clinical and prognostic indicators and treatment options such as forced alkaline diuresis, mannitol therapy, dialysis and haemofiltration. We discuss more controversial treatment options such as allopurinol, potassium binders, calcium therapy and other diuretics. We also discuss the specific management issues of the secondary ‘renal disaster’ that can occur following earthquakes and other mass disasters. Part 2: The local injury, we look in more detail at the pathophysiology of skeletal muscle damage following crush injuries and discuss how to minimise morbidity by salvaging limb function. In particular we discuss the controversies surrounding fasciotomy of crushed limbs and compare surgical management with conservative techniques such as mannitol therapy, hyperbaric oxygen therapy, topical negative pressure therapy and a novel topical treatment called gastric pentadecapeptide BPC 157.

IntroductionAlthough gastrointestinal haemorrhage from aortoduodenal fistulae secondary to previous aortic grafts are well known, a primary fistula from an aortic aneurysm is a rare consideration resulting in inappropriate management and poor outcomes.Case presentationWe report a previously fit 65-year-old Sri Lankan man who presented with severe anaemia (haemoglobin, 6 gm/dl), recent onset low backache. There was no history of analgesic abuse, peptic ulceration, alcohol excess, weight loss or malena. The abdomen was soft and there was no visceromegaly. A routine ultrasound detected an abdominal aortic aneurysm without signs of a leak. Two days later, while undergoing routine diagnostic tests for anaemia and backache, he had a massive haematemesis. Standard resuscitation was commenced with hope that common sources, either peptic ulcers or varicies would eventually stop bleeding enabling endoscopy and definitive treatment. However, persistent hypotension coupled with the clinical suspicion of an aortoduodenal fistula led to immediate surgical exploration rather than continued aggressive resuscitation. An aortoduodenal fistula was confirmed and both the duodenum and the aorta were successfully repaired by direct suture and synthetic graft replacement respectively. This man remains well nine months later.ConclusionGastrointestinal bleeding in the presence of an ‘asymptomatic’ abdominal aortic aneurysms should be assumed to be from a primary aortoduodenal fistula unless another source can be identified with certainty without delay.

External fixation is a commonly used method in stabilizing fracture sites. The performance of the fixator depends on how it affects the mechanical properties of the fracture site and is governed by parameters like the fixator type and fixator configuration. Identifying ideal configurations prior to surgery will help surgeons in planning the procedure, limiting the possibility of complications such as non-union. In this study, a framework has been proposed as a surgical pre-planning tool, to assist surgeons compare mechanical properties of a fracture site under different fixator configurations, and thereby identify the optimum solution. A computational tool was identified as the best method for this purpose. Cost and time of computation were given special consideration to reduce complexity in clinical settings. A pilot study was conducted on a section of the proposed framework, where the aim was to understand the feasibility of implementation. In the pilot study, a unilateral uni-planar fixator on a simple diaphyseal transverse fracture was analyzed. During the pilot study the selected fixator was tested and a few models were developed to assess system stability. The models were then compared to identify the optimum model that could be used with the proposed framework. The proposed framework provided a suitable solution for the use case and out of the models developed the simplified finite element model was identified as the best option for the use case.

Embolotherapy of arteriovenous malformations (AVM) is not without risk. A 28-year-old woman underwent transcatheter selective embolisation of an AVM in the cheek using polyvinyl alcohol (PVA) microparticles. She became hypoxic and hypotensive post procedure, and had repeated cardiorespiratory arrests despite aggressive support. Resistant hypoxia with gross right heart dilatation on echocardiography suggested extensive pulmonary embolism. She died 24 h later. A postmortem confirmed widespread thrombosis and PVA particles in the pulmonary microvasculature identical to that in the treated AVM. This is the first reported death from PVA particle pulmonary embolism following therapeutic embolisation of a peripheral AVM.

No abstract

No abstract