Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review

Background Gastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify. Case presentation A young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass. Conclusions Assessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

A comparative evaluation of intravenous dexmedetomidine and oral clonidine in attenuating the rise in intra ocular pressure

Background: Administration of Suxamethonium, laryngoscopy and intubation is associated with rise in intraocular pressure (IOP). The need to attenuate rise in IOP is of utmost importance, especially in patients with perforating injury of the eyeball. The present study was undertaken to compare the effectiveness of intravenous Dexmedetomidine 0.4μg/kg and oral Clonidine 3μg/kg in attenuating the rise in IOP following administration of suxamethonium, laryngoscopy and intubation.Methods: 150 patients of ASA I or II, aged between 18-60 years, who were posted for elective non-ophthalmic surgery requiring general anaesthesia were included in this study. Patients were randomly divided into 3 groups with 50 patients in each group. Group-D: Received 0.4μg/kg IV dexmed in 10ml sterile water, over 10 min before induction. Group-C: Received 3μg/kg oral clonidine two hours prior to surgery. Group-S: Control group.Results: IOP, MAP, and HR were recorded at baseline, before induction, after induction, 1 min, 3 min and 5 min after administration of suxamethonium. Although Suxamethonium laryngoscopy and intubation increased IOP in all the 3 groups there was significant reduced rise in IOP noted in dexmed group and clonidine group compared to study group (p= <0.001). Furthermore, patients in dexmed group had lesser rise in IOP compared to clonidine group (p= <0.001).Conclusions: We concluded that both intravenous dexmedetomidine 0.4μg/kg and oral clonidine 3μg/kg, significantly attenuated the rise in IOP associated with administration of suxamethonium, laryngoscopy and intubation. However intravenous dexmedetomidine proved better than oral clonidine in attenuating the rise in IOP.

Safe management of paediatric penetrating head injury without a CT scanner: A strategy for humanitarian surgeons based on experience in southern Afghanistan

Introduction In many parts of the world, access to a CT scanner remains almost non-existent, and patients with a head injury are managed expectantly, often with poor results. Recent military medical experience in southern Afghanistan using a well-equipped surgical facility with a CT scanner has provided new insights into safe surgical practice in resource-poor environments. Methods All cases of children aged under 16 years with penetrating head injury who were treated in a trauma unit in southern Afghanistan by a single neurosurgeon between 2008 and 2010 were reviewed. Based on a previously published retrospective review, a clinical strategy aimed specifically at generalist surgeons is proposed for selecting children who can benefit from surgical intervention in environments with no access to CT scanners. Results Fourteen patients were reviewed, of whom three had a tangential wound, 10 had a penetrating wound with retained fragments and one had a perforating injury. Two operations for generalist surgeons are described in detail: limited wound excision; and simple decompression of the intra-cranial compartment without brain resection or dural repair. Conclusions In resource-poor environments, clinically-based criteria may be used as a safe and appropriate strategy for selecting children who may benefit from relatively straightforward surgery after penetrating brain injury.