INTRODUCTION: Tension pneumopericardium is a life-threatening condition, manifesting most commonly as hemodynamic instability caused by cardiac tamponade. Reduced cardiac output and blood pressure can lead to difficulties in the detection of arterial bleeding from associated injuries while the increased venous pressure can increase the rate of bleeding. CASE REPORT: This is the case of a patient after a car accident, with bilateral serial fractures, bilateral pulmonary contusion, bilateral pneumothorax, emphysema of the neck and chest, pneumomediastinum and pneumopericardium, and other injuries. During treatment, the patient developed a gradually progressing hemodynamic instability, resulting in pulseless electrical activity. Further progression of the case is detailed in the paper. CONCLUSIONS: Tension pneumopericardium is a rare complication of a high-energy blunt thoracic trauma that manifests through hemodynamic instability. Its treatment requires early diagnosis and immediate decompression of the pericardial cavity, which should, where possible, be performed even before putting the patient on mechanical ventilation as ventilation bears a high risk of worsening the pneumopericardium due to the increased air pressure in the lungs. During diagnosis and treatment of associated injuries, we must bear in mind that the hemodynamic changes caused by pneumopericardium can mask typical signs of such injuries.
Foramen ovale patens je přetrvávající komunikace mezi levou a pravou síní, většinou asymptomatická, nacházející se zhruba u 25 % populace. Za normálních okolností je kanál neprůchodný nebo s hemodynamicky nevýznamným levopravým zkratem. Avšak v případě vzestupu tlaku v pravé síni, jako tomu je například při akutní plicní embolii, může dojít k pravolevému zkratu s rizikem paradoxní embolie do systémového řečiště včetně ischemické cévní mozkové příhody. V kazuistice je prezentována pacientka s tromboembolickou nemocí vyvolanou recentním polytraumatem, u které došlo k zaklínění objemného trombu ve foramen ovale patens - tedy k hrozící paradoxní embolii. Vzhledem ke kontraindikaci kardiochirurgického řešení i systémové trombolýzy byla pacientka léčena konzervativně, a to antikoagulační terapií nefrakcionovaným heparinem a warfarinem. Echokadiograficky jsme zdokumentovali postupné kompletní rozpuštění trombu, které nastalo 6 měsíců od stanovení diagnózy, a to bez známek systémové embolie.
Patent foramen ovale is a persisting communication between the left and right atrium, present in approximately 25% of population, usually asymptomatic. Under normal conditions there is either no blood flow or a hemodynamically nonsignificant left-to-right shunt between the atria. However, increased right atrium pressure, as it is in pulmonary embolism, can make PFO a right-to-left shunt and poses a risk of paradoxical systemic embolism, including the risk of ischemic stroke. Here we report a case of a patient presenting with venous thromboembolism provoked by a recent polytrauma. We identified a large thrombus stuck in patent foramen ovale – an impending paradoxical embolism. Both surgical intervention and systemic thrombolysis were contraindicated so the patient was administered an anticoagulation treatment with unfractionated heparin and warfarin. By frequent echocardiography we were able to monitor complete resolution of the thrombus by 6 months from the diagnosis, with no systemic embolism.
- MeSH
- Computed Tomography Angiography methods MeSH
- Echocardiography methods MeSH
- Foramen Ovale, Patent * etiology drug therapy MeSH
- Humans MeSH
- Pulmonary Embolism * diagnosis drug therapy MeSH
- Multiple Trauma complications MeSH
- Aged, 80 and over MeSH
- Thrombosis drug therapy MeSH
- Treatment Outcome MeSH
- Warfarin therapeutic use MeSH
- Check Tag
- Humans MeSH
- Aged, 80 and over MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
- MeSH
- Fibrinogen administration & dosage standards MeSH
- Hemostatics therapeutic use MeSH
- Blood Transfusion MeSH
- Hemorrhage * etiology classification therapy MeSH
- Humans MeSH
- Critical Care MeSH
- Multiple Trauma complications therapy MeSH
- Blood Component Transfusion standards MeSH
- Check Tag
- Humans MeSH
- Publication type
- Newspaper Article MeSH
Cíl studie: Sledování kinetiky calprotectinu a calgranulinu C v krvi u polytraumatizovaných pacientů, posouzení sérových koncentrací obou proteinů jako prediktorů nozokomiální infekce a srovnání sérových koncentrací calprotectinu a calgranulinu C s rutinními prozánětovými faktory a skórovacími systémy. Typ pracoviště: Pracoviště intenzivní medicíny fakultní nemocnice. Typ studie: Monocentrická prospektivní studie. Materiál a metoda: Do studie bylo zařazeno 25 pacientů s polytraumatem a 20 zdravých dobrovolníků. Pacientům byla odebrána krev při příjmu (1. den) a 3., 5. a 7. den hospitalizace a byla stanovena sérová koncentrace calprotectinu a calgranulinu C enzymoimunoanalyticky. Pacienti byli skórováni dle Injury Severity Score, Acute Physiology And Chronic Health Evaluation II a Sequential Organ Failure Assessment Score (SOFA). Z rutinních laboratorních parametrů byl stanoven počet leukocytů, C-reaktivní protein (CRP), prokalcitonin (PCT), glykemie, laktát. Dále byl sledován případný rozvoj nozokomiální infekce. Výsledky: U polytraumatizovaných pacientů byly zjištěny signifikantní elevace sérové koncentrace calprotectinu a calgranulinu C oproti zdravým kontrolám po celou dobu sledování. Dále byla zjištěna pozitivní korelace mezi oběma proteiny a SOFA skóre 1. a 3. den hospitalizace. Calprotectin a calgranulin C pozitivně korelovaly 3. den s CRP a PCT a calprotectin koreloval s CRP i 5. den studie. Patrný byl trend nižší koncentrace calprotectinu a calgranulinu C u 10 pacientů s nozokomiální infekcí a u těchto nemocných byla pozorována 1., 3. a 5. den signifikantně vyšší glykemie oproti pacientům bez infekční komplikace (n = 8). Závěr: Výsledky naznačují využití sérových koncentrací calprotectinu a calgranulinu C jako potencionálních biomarkerů polytraumatu.
Objective: To study the kinetics of calprotectin and calgranulin C in the serum of patients with polytrauma, to evaluate the serum levels of both the proteins as predictors of nosocomial infection (NI), and to compare calprotectin and calgranulin C with routine biomarkers and scoring systems. Design: Monocentric, prospective, clinical study Setting: University Hospital ICU Materials and methods: The study included 25 polytrauma patients and 20 healthy volunteers. The blood specimens were collected on admission (day 1) and then on days 3, 5 and 7 of hospitalization. Concentrations of calprotectin and calgranulin C were determined by enzyme immunometric assay. Patients were scored with Injury Severity Score, Acute Physiology And Chronic Health Evaluation II a Sequential Organ Failure Assessment Score (SOFA). The white blood cell count and the serum concentrations of the C-reactive protein (CRP), procalcitonin (PCT), glucose and lactate were the measured routine biomarkers. Other parameters included length of ICU stay, duration of mechanical ventilation, antibiotic therapy and development of nosocomial infection. Results: Significant elevations of the calprotectin and calgranulin C serum levels in trauma patients in comparison to healthy subjects were observed during the whole study period. Concentrations of both the proteins correlated positively with the SOFA score on days 1 and 3, CRP and PCT on day 3; and calprotectin also correlated with CRP on day 5. A trend of low serum levels of calprotectin a calgranulin C was observed in patients with nosocomial infection (n=10). In addition, these patients had significantly higher glycaemia on days 1, 3 and 5 in comparison to patients without infectious complication (n=8). Conclusions: The results suggest calprotectin and calgranulin C serum levels as suitable biomarkers of severe injury.
- MeSH
- C-Reactive Protein analysis MeSH
- Cross Infection diagnosis etiology MeSH
- Data Interpretation, Statistical MeSH
- Calcitonin blood MeSH
- Leukocyte L1 Antigen Complex * analysis pharmacology MeSH
- Humans MeSH
- Critical Care MeSH
- Multiple Trauma * diagnosis complications pathology MeSH
- Prospective Studies MeSH
- S100A12 Protein * pharmacology blood MeSH
- Organ Dysfunction Scores MeSH
- Check Tag
- Humans MeSH
- Publication type
- Research Support, Non-U.S. Gov't MeSH
- MeSH
- Time-to-Treatment MeSH
- Fibrinogen administration & dosage MeSH
- Blood Coagulation Disorders diagnosis etiology therapy MeSH
- Hemorrhage etiology therapy MeSH
- Tranexamic Acid therapeutic use MeSH
- Humans MeSH
- Emergencies MeSH
- Critical Care MeSH
- Multiple Trauma complications MeSH
- Check Tag
- Humans MeSH
- Publication type
- Newspaper Article MeSH
AIMS: Critically ill patients undergoing aggressive fluid resuscitation and treated empirically with hydrosoluble time-dependent beta-lactam antibiotics are at risk for sub-therapeutic plasma concentrations. The aim of this study was to assess the impact of two covariates - creatinine clearance (Clcr) and cumulative fluid balance (CFB) on pharmacokinetics/pharmacodynamics (PK/PD) target attainment within a week of treatment with meropenem (ME) or piperacillin/tazobactam (PIP/TZB). METHODS: In this prospective observational pharmacokinetic (PK) study, 18 critically ill patients admitted to a surgical Intensive Care Unit (ICU) were enrolled. The primary PK/PD target was free antibiotic concentrations above MIC at 100% of the dosing interval (100%fT>MIC) to obtain maximum bactericidal activity. Drug concentration was measured using liquid chromatography-tandem mass spectrometry. RESULTS: The treatment of both 8 septic patients with IV extended ME dosing 2 g/3 h q8 h and 10 polytraumatized patients with IV intermittent PIP/TZB dosing 4.0/0.5 g q8 h was monitored. 8/18 patients (44%) manifested augmented renal clearence (ARC) where Clcr ≥130 mL/min/1.73 m2. Maximum changes were reported on days 2-3: the median positive CFB followed by the large median volume of distribution: Vdme=70.3 L (41.9-101.5), Vdpip = 46.8 L (39.7-60.0). 100%fTme>MIC was achieved in all patients on ME (aged ≥60 years), and only in two patients (non-ARC, aged ≥65 years) out of 10 on PIP/TZB. A mixed model analysis revealed positive relationship of CFBpip with Vdpip (P=0.021). CONCLUSION: Assuming that the positive correlation between CFB and Vd exists for piperacillin in the setting of the pathological state, then CFB should predict Vdpip across subjects at each and every time point.
- MeSH
- Anti-Bacterial Agents administration & dosage pharmacokinetics pharmacology MeSH
- beta-Lactams administration & dosage pharmacokinetics pharmacology MeSH
- Adult MeSH
- Critical Illness therapy MeSH
- Middle Aged MeSH
- Humans MeSH
- Meropenem administration & dosage pharmacokinetics pharmacology MeSH
- Adolescent MeSH
- Young Adult MeSH
- Peritonitis complications drug therapy MeSH
- Piperacillin administration & dosage pharmacokinetics pharmacology MeSH
- Multiple Trauma complications drug therapy MeSH
- Prospective Studies MeSH
- Drug Administration Schedule MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Sepsis drug therapy MeSH
- Shock, Septic drug therapy MeSH
- Systemic Inflammatory Response Syndrome drug therapy MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Adolescent MeSH
- Young Adult MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Observational Study MeSH
- MeSH
- Antifibrinolytic Agents administration & dosage MeSH
- Adult MeSH
- Fibrinogen analysis administration & dosage MeSH
- Precision Medicine MeSH
- Blood Coagulation Disorders diagnostic imaging etiology drug therapy MeSH
- Blood Transfusion methods MeSH
- Hemorrhage etiology drug therapy MeSH
- Tranexamic Acid administration & dosage MeSH
- Humans MeSH
- Critical Care MeSH
- Point-of-Care Testing trends MeSH
- Multiple Trauma etiology surgery complications MeSH
- Blood Component Transfusion methods MeSH
- Thrombelastography methods instrumentation MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
- Newspaper Article MeSH
- MeSH
- Antifibrinolytic Agents administration & dosage standards MeSH
- Adult MeSH
- Blood Coagulation Disorders diagnosis etiology drug therapy MeSH
- Hemorrhage * etiology drug therapy MeSH
- Tranexamic Acid administration & dosage pharmacology MeSH
- Humans MeSH
- Point-of-Care Testing MeSH
- Multiple Trauma complications MeSH
- Thrombelastography methods instrumentation MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
Current polytrauma management is multidisciplinary, with Damage Control Surgery (DCS), Damage Control Orthopaedics (DCO) and Damage Control Resuscitation (DCR) being applied in the first few hours after injury. The most severe group of polytrauma patients are those with circulatory instability and massive blood loss as a consequence of unstable pelvic fractures. In treating these patients, of crucial importance is the speed and quality of stabilisation of pelvic fracture fragments. The authors present two case reports of polytrauma patients with unstable pelvic fractures, in whom open reduction and internal fixation was performed on the anterior fracture segment through extended laparotomy in order to stop bleeding into the abdominopelvic cavity as part of the DCS approach. Key words: exsanguination, polytrauma, unstable pelvic fracture, plate fixation.
- MeSH
- Fractures, Bone diagnostic imaging surgery MeSH
- Hemostasis, Surgical methods MeSH
- Bone Plates * MeSH
- Humans MeSH
- Emergencies MeSH
- Pelvic Bones injuries MeSH
- Multiple Trauma complications surgery MeSH
- Fracture Fixation, Internal * methods MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Case Reports MeSH
