EP.FRI.42 REBOA associated iatrogenic AV fistula

Aim To discuss a rarely reported complication of Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a trauma patient with exsanguating haemorrhage. Case description A 15 year old male sustained was brought in as a cod Red, following multiple stab injuries to his Rt thigh. A REBOA was inserted via the contralateral Femoral artery on the scene to control the bleeding. Once proximal and distal control was obtained on the Right leg, the REBOA was deflated and removed. The right leg needed an interposition vein graft and ligation of femoral vein. The patient had received 12 units of transfusion. Post-operative CT-angiogram demonstrated an AV fistula between the Left Profunda femoris artery and Common femoral vein on the side of REBOA insertion. A Duplex scan showed flows of 2600ml/min on duplex and AVF diameter of 2.6mm. It was decided to wait for spontaneously closure as patient underwent rehab. At 6 weeks the AVF flow had reduced to 460ml/min however further expectant management did not lead to spontaneous closure of the AVF and he underwent surgical tie off during his next school holidays 6 months later. Conclusion AV fistula formation as a complication of REBOA insertion has not been reported in paediatric population. It highlights the need for a CT angio after surgical stabilisation. These post traumatic AVFs may need surgical repair if it does not spontaneously close in 3-6 month time.

Arrow-Shot Injury to Pediatric Spinal Cord

Penetrating spinal cord injuries (PSCI) in cervical region are extremely rare in pediatric population. Most injuries in pediatric population are accidental due to gunshot or a stab injury with a sharp or pointed object. Gun shots may result into a severe wound which is usually fatal and may result in death, quadriplegia, or serious long-term disability. Stab injuries are less severe and may result in neurological sequalae. In this paper, an unusual case of pediatric arrow shot partial cervical cord injury is reported which was managed by aggressive neurosurgical management. The arrow lodged in the cervical cord was very near to the vertebral artery leading to parapariesis which recovered well without any complications. Diagnostic imaging at admission included radiographs, computed tomography (CT), and CT angiography of the cervical region. The patient underwent early surgical intervention with removal of foreign body from the cord and subsequent dural suturing.

The Home Accident Cases Applying to The Pediatric Emergency Department during the Covid-19 Pandemic: What Did the Pandemic Change?

Background: Whether the pandemic caused an increase in the number of home accidents (HA) admitted to the pediatric emergency department (PED) was investigated. Applications in a similar quarter in 2019 and 2020 were compared. Methods: The study was retrospective. Their demographic data, the reason for admission to the hospital, the time of admission, the length of hospital stay, intensive care rate, and interventional procedures were recorded. The two groups were compared to find whether there was any difference. Results: There were 700 and 597 admissions for specified reasons during the specified period in 2019 and 2020, respectively. In 2019, 9.46% of all cases admitted to the PED were HA whereas the rate was 24.43% in 2020. The male/female ratios were similar (p=0.520). The median age in 2020 (36 months) was significantly higher than that in 2019 (33 months) (p=0.010). The main clinical presentations also differed significantly. The incidence of falls, the gastric/intestinal foreign bodies, and the penetrating stab injuries were significantly higher in those in 2020 (p<0.001). Significant differences were also found regarding diagnostic and therapeutic interventions. During the specified period in 2019, 623 patients (89.5%) were discharged from the PED. The rate of discharge in 2020 (84.9%) was significantly lower. Also, there were significantly more hospitalizations in other wards in 2020 than those in 2019 (3.7% vs. 1.0%) (p=0.004). Conclusion: The Covid-19 pandemic caused an increase in the number of HAs cases admitted to the PED relative to all hospital admissions. The most common type of accident was falls, as in the non-pandemic period. The pandemic caused delays in accessing healthcare services, especially for critically ill patients, more frequent hospitalizations, and a decrease in the rate of discharge from the PED.

Near-transection of abdominal aorta due to stab injury: a case report

Abdominal vascular injuries are amongst the most lethal injuries encountered by modern day trauma and vascular surgeons. Penetrating injuries to aorta have a wide spectrum of presentation mortality being 50-70%. 38-year-old male presented to emergency department with stab injury to abdomen with a knife stuck in-situ. Patient was conscious with herniating bowel loops from stab site. Bilateral limbs had good pulsations and no neurological deficit. Patient was taken for emergency laparotomy and found to have complete jejunal transection with near transection of aorta with knife stuck in the vertebra. Primary repair of aorta was done with prolene 5-0 along with jejuno-jejunal anastomosis. Patient was transfused with 12 units of blood and 8 units of FFP. Postoperatively patient recovered well and was discharged on post-operative day (POD) 14 with good recovery and follow up was uneventful. Spectrum of penetrating aortic injuries varies from stable patients to severely exsanguinated in vicious cycle of shock, acidosis, coagulopathy and arrhythmias causing high mortality and morbidity. Our case had contained retroperitoneal hematoma with stable vitals and good general condition and due to early diagnosis and timely institution of surgery the patient survived and recovered uneventfully. All abdominal stab injuries are to be taken as having vascular injuries. Surgery has to be taken up as an integral part of resuscitation with quickest and most effective diagnostics along with lifesaving procedures to have lesser morbidity and mortality.

An Atypical Self-Inflicted Abdominal Stab Injury: A Case Report

When dealing with cases of sharp force penetrating injuries, survival of the victim depends on injury to major blood vessels or major organs resulting in internal or external hemorrhage. Stab with intention of homicide although common, self inflicted stab injuries are less reported. We present an unusual self inflicted stab injury over an abdomen extending from front to back of the abdomen over epi-gastric region by a 52 years old male who managed to survive as it missed all the major blood vessels and solid organs that lied in between. On observation of characteristics of the wound, we have made an attempt to opine that the incident was self- inflicted with suicidal intentions.

Endovascular Management of Lower Limb Arteriovenous Fistula Presenting 8 Years After Gunshot Injury

Trauma is a common cause of arteriovenous fistula resulting from iatrogenic or penetrating injuries such as gunshot wounds, stab injuries, and so on. Endovascular management using stent grafts is a minimally invasive method to manage these complex vascular injuries. We present a case report of a young male patient who presented to us with complaint of progressively increasing swelling in the left lower limb 8 years after gunshot injury to that limb. Stent grafts were deployed to reconstruct the artery and to occlude the fistulous site.

Self-Inflicted Stab Wounds: A Single-Center Experience from 2010 to 2016

Despite low mortality rates, self-inflicted stab wounds (SISWs) can result in significant morbidity and often reflect underlying substance abuse and mental health disorders. This study aimed to characterize demographics, comorbidities, and outcomes seen in self-inflicted stabbings and compare these metrics to those seen in assault stabbings. A Level I trauma center registry was queried for patients with stab injuries between January 2010 and December 2015. Classification was based on whether injuries were SISWs or the result of assault stab wounds (ASWs). Demographic, injury, and outcome measures were recorded. Differences between genders, ethnicities, individuals with and without psychiatric comorbidities, and SISW and ASW patients were assessed. Within the SIWS cohort, no differences were found when comparing age, gender, or race, including need for operative intervention. However, patients with psychiatric histories were less likely to have a positive toxicology test on arrival than those without psychiatric histories (22% vs. 0%, P = 0.04). When compared with 460 ASW patients, SISW were older (41 vs. 35, P < 0.001), more likely to be white (92% vs. 64%, P < 0.001), more likely to have a psychiatric history (15% vs. 4%, P < 0.001), require operative intervention (65% vs. 50%, P = 0.008), and be discharged to a psychiatric facility (47% vs. 0.2%, P < 0.001). SISW patients have higher rates of psychiatric illness and an increased likelihood to require operative intervention as compared with ASW patients. This population demonstrates an acute need for both inpatient and outpatient psychiatric care with early involvement of multidisciplinary teams for treatment and discharge planning.