Alan Tyroch

BACKGROUND: Patients with moderate and severe traumatic brain injury (TBI) are at risk for secondary brain insults such as thrombocytopenia and coagulopathy. This study assessed the development of thrombocytopenia and coagulopathy at admission and within the subsequent 72 hours after TBI. METHODS: Blunt trauma patients with moderate or severe TBI and an extracranial Abbreviated Injury Scale score less than 3 were reviewed. Data collection included initial and subsequent prothrombin time, partial thromboplastin time, and platelet values. RESULTS: On initial evaluation, thrombocytopenia was present in 14% and coagulopathy in 21% of patients. By the third day, thrombocytopenia and coagulopathy increased to 46% and 41%, respectively. Of patients who died, 67% had thrombocytopenia and 62% had coagulopathy. CONCLUSION: Patients with moderate and severe TBI are at risk for thrombocytopenia and coagulopathy, not only at admission but also on subsequent laboratory examination. Repeat laboratory evaluation is warranted even if initial results are normal in this population.

Adult respiratory distress syndrome (ARDS) has a high mortality. Its only effective treatment is respiratory therapy. If this fails mortality is probably 100 per cent. No other treatment for ARDS has proved effective including "magic bullets." Twenty patients suffering from ARDS secondary to trauma and/or sepsis failed to respond to treatment with mechanical ventilation and positive end-expiratory pressure. On the assumption that disseminated intravascular coagulation initiates ARDS by occluding the pulmonary microcirculation with microclots, the patients were treated with plasminogen activators. The patients responded with significant improvement in partial pressure of oxygen in arterial blood. No bleeding occurred and clotting parameters remained normal. We conclude that ARDS can be safely treated with plasminogen activator.

First described by S.E. Duplay in 1833, acute gastric dilatation has since been well documented in the literature. Several theories of the pathogenesis of acute gastric dilatation have been postulated. In 1842, Karl Freiherr von Rokitansky described the superior mesenteric artery syndrome, followed by W. Brinton in 1859 with the atonic theory. C.R. Morris et al. introduced debilitation and anesthesia as predisposing factors. Although rare, gastric necrosis is the most severe consequence of acute gastric dilatation. Vascular insufficiency secondary to increased intragastric pressure is the critical factor. We report an unusual case of acute gastric dilatation with subsequent necrosis of uncertain etiology.

BACKGROUND: Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. METHODS: Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. RESULTS: Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. CONCLUSION: Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.