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Thursday, December 20, 2018
Alligator attacks,Caiman's bite
| CASE REPORT | |
|
Thoracic trauma by black caiman's bite in the Amazon region
João José Corrêa Bergamasco, Raquel Magalhães Pereira, Juan Eduardo Rios Rodriguez, Brígida Thaine Fernandes Cabral
Department of General Surgery, Getúlio Vargas University Hospital – HUGV, Federal University of Amazonas, Manaus, Amazonas, Brazil
| Date of Web Publication | 20-Dec-2018 |
Correspondence Address:
João José Corrêa Bergamasco
Alligator attacks are rare, even in the Amazon region, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. We must consider that the Amazon region has two species of different genera that are passing through an intense moment of population recovering for the last two decades after a period of predatory exploitation, and they are still the most abundant crocodilians on the region being them the spectacled caiman (Caiman crocodilus) and the black caiman (Melanosuchus niger).[1] There are few reports of accidents by these animals, most related to smaller species, such as Caiman yacare (Yacare caiman) and Caiman latirostris (broad-snouted caiman). However, the reported species hereafter is the M. niger, or the black caiman, from the Amazon rainforest, it presents a large size compared to the others, and it attacks humans for predation, not being considered just accidents as with other species.[2],[3] Another important factor to be quoted is the seasonal period of alligator appearance, mostly present on low water level periods of the river, facilitating attacks on the surface; moreover, it is a common period of animals' egg's incubation. At this time of year, there are many other species that feed on these eggs, which increase the rate of aggressive alligators on the surroundings.[4]
The patient, a 32-year-old man, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite (M. niger). According to the reports, the victim was fishing in a river near his city on a canoe, followed by his wife on another canoe, when the animal with approximately 5 m length got on the patient's boat, attacking his chest, releasing him only because his wife attacked the alligator with wood pieces. In his admission, he appeared to be slightly dyspneic and has chest pain, respiratory rate of 22 rpm, heartbeat of 106, and normal values of blood pressure.
The physical examination showed extensive lacerations at the left hemithorax [Figure 1] and [Figure 2], with loss of soft parts at the thoracic wall, rib fractures, lung parenchyma exposure, and muscular tissue wounds. The first step was inserted a chest drain of 28 French inside a wound to drain a severe purulent fluid. The leukogram showed a raise of leukocytes rate (20,451).
The patient was immediately forwarded to surgery center, where was performed a left anterolateral thoracotomy showing pleural adhesions at the chest wall, pleural cavity cleaning, partial pulmonary decortication, cleaning and debridement of the thoracic wall muscles, partial excision of the ribs (ribs 7/8/9), and a closed chest drain with water seal, associated with collagenase dressing. After 24 h of evolution at intensive care, the vital signals were stable, blood pressure levels were 90/50 mmHg, cardiac frequency: 72 bpm, saturation: 96%, and temperature: 36.5°C, accepting oral diet, without pulmonary symptoms, but with chest tube inserted. Thorax radiography showed opacity at left lung, more intense between superior and inferior lobe [Figure 3]. At the 3rd day after the surgery, the levels of blood in chest drain had an important decrease but still with bubbles and serous liquid, without smell. At 10 day of postoperatory, thorax radiography was solicited, with a residual opacification between superior and inferior lung lobe [Figure 4]. After 11 days, the drainage tube had no bubbles or serous liquid and was removed after this.
He remained hospitalized for 15 days with parenteral antibiotic therapy (6 days of cefepime +8 days of meropenem) because of extensive and unspecific microbiota of alligator jaws. He evolved well at postoperative, with radiological and drainage volume control, withdrawn at the 14th day after surgery and decrease of leukocytes levels. Received discharge clinically well with residual pulmonary opacification at the left hemithorax.
Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite, lethal against children and small-sized people. The main complications due an attack of this kind are tissue lesions that depending on the affected region may compromise functions or losing limbs; blood loss, due the wound depth, hits blood vessels, leading to hypovolemic shock in cases, like the one related above; and infection, due the bacterial flora present in the alligator's mouth.[5],[6],[7] The most attacked anatomic parts are the inferior limbs, being able to lead to amputation if the initial medical care takes too long.
The early debridement and the hypovolemic and infectious states stabilization are the initial goals on this situation because they are the main causes of death.[8] It is important to mention that great thoracic traumas are very complicated to handle due the vital organs and easily traumatized when submitted to high strength, like an alligator bite, that can be ranged from 217 to 13,172 N, leading to an increase of the mortality in similar cases, which tends to be the focus of researches in the next years.[9],[10]
Acknowledging few published reports by trustful sources, a case like the reported above fits in every way like a hard situation to care. Since the injury was on an atypical place (the thorax), the severity of the symptoms was increased, leading to dyspnea and huge blood loss. Added to this, there is the difficulty of the Amazon region, mostly on the riverside communities, which does not have a good emergency support in cases of this magnitude, needing to go to a specialized center, most of the time in Manaus to receive a proper care. So, considering infectious factors, prognosis was poor due to the late beginning of antibiotics and surgical cleaning of the wounds (on the third day after trauma), what makes this case even more relevant for its favorable outcome.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
Department of General Surgery, Getúlio Vargas University Hospital – HUGV, Federal University of Amazonas, Manaus, Amazonas
Brazil
| Abstract |
Alligator attacks are rare, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. There are few reports of accidents by these animals. The reported species hereafter is the Melanosuchus niger from the Amazon rainforest. The patient aged 32 years, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite. Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite. Cases like this are not easy to conduct. Since the injury was on an atypical place, the severity of the symptoms was increased, leading to dyspnea and huge blood loss.
Keywords: Bites and stings, penetrating, wounds, wounds and injuries
| Introduction |  |
Alligator attacks are rare, even in the Amazon region, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. We must consider that the Amazon region has two species of different genera that are passing through an intense moment of population recovering for the last two decades after a period of predatory exploitation, and they are still the most abundant crocodilians on the region being them the spectacled caiman (Caiman crocodilus) and the black caiman (Melanosuchus niger).[1] There are few reports of accidents by these animals, most related to smaller species, such as Caiman yacare (Yacare caiman) and Caiman latirostris (broad-snouted caiman). However, the reported species hereafter is the M. niger, or the black caiman, from the Amazon rainforest, it presents a large size compared to the others, and it attacks humans for predation, not being considered just accidents as with other species.[2],[3] Another important factor to be quoted is the seasonal period of alligator appearance, mostly present on low water level periods of the river, facilitating attacks on the surface; moreover, it is a common period of animals' egg's incubation. At this time of year, there are many other species that feed on these eggs, which increase the rate of aggressive alligators on the surroundings.[4]
| Case Report | |
The patient, a 32-year-old man, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite (M. niger). According to the reports, the victim was fishing in a river near his city on a canoe, followed by his wife on another canoe, when the animal with approximately 5 m length got on the patient's boat, attacking his chest, releasing him only because his wife attacked the alligator with wood pieces. In his admission, he appeared to be slightly dyspneic and has chest pain, respiratory rate of 22 rpm, heartbeat of 106, and normal values of blood pressure.
The physical examination showed extensive lacerations at the left hemithorax [Figure 1] and [Figure 2], with loss of soft parts at the thoracic wall, rib fractures, lung parenchyma exposure, and muscular tissue wounds. The first step was inserted a chest drain of 28 French inside a wound to drain a severe purulent fluid. The leukogram showed a raise of leukocytes rate (20,451).
 | Figure 1: Thoracic region with wounds sutured or not Click here to view |
 | Figure 2: Extensive thoracic lesions Click here to view |
The patient was immediately forwarded to surgery center, where was performed a left anterolateral thoracotomy showing pleural adhesions at the chest wall, pleural cavity cleaning, partial pulmonary decortication, cleaning and debridement of the thoracic wall muscles, partial excision of the ribs (ribs 7/8/9), and a closed chest drain with water seal, associated with collagenase dressing. After 24 h of evolution at intensive care, the vital signals were stable, blood pressure levels were 90/50 mmHg, cardiac frequency: 72 bpm, saturation: 96%, and temperature: 36.5°C, accepting oral diet, without pulmonary symptoms, but with chest tube inserted. Thorax radiography showed opacity at left lung, more intense between superior and inferior lobe [Figure 3]. At the 3rd day after the surgery, the levels of blood in chest drain had an important decrease but still with bubbles and serous liquid, without smell. At 10 day of postoperatory, thorax radiography was solicited, with a residual opacification between superior and inferior lung lobe [Figure 4]. After 11 days, the drainage tube had no bubbles or serous liquid and was removed after this.
 | Figure 3: Chest radiography (before surgery) Click here to view |
 | Figure 4: Chest radiography (14 days after surgery) Click here to view |
He remained hospitalized for 15 days with parenteral antibiotic therapy (6 days of cefepime +8 days of meropenem) because of extensive and unspecific microbiota of alligator jaws. He evolved well at postoperative, with radiological and drainage volume control, withdrawn at the 14th day after surgery and decrease of leukocytes levels. Received discharge clinically well with residual pulmonary opacification at the left hemithorax.
| Discussion | |
Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite, lethal against children and small-sized people. The main complications due an attack of this kind are tissue lesions that depending on the affected region may compromise functions or losing limbs; blood loss, due the wound depth, hits blood vessels, leading to hypovolemic shock in cases, like the one related above; and infection, due the bacterial flora present in the alligator's mouth.[5],[6],[7] The most attacked anatomic parts are the inferior limbs, being able to lead to amputation if the initial medical care takes too long.
The early debridement and the hypovolemic and infectious states stabilization are the initial goals on this situation because they are the main causes of death.[8] It is important to mention that great thoracic traumas are very complicated to handle due the vital organs and easily traumatized when submitted to high strength, like an alligator bite, that can be ranged from 217 to 13,172 N, leading to an increase of the mortality in similar cases, which tends to be the focus of researches in the next years.[9],[10]
Acknowledging few published reports by trustful sources, a case like the reported above fits in every way like a hard situation to care. Since the injury was on an atypical place (the thorax), the severity of the symptoms was increased, leading to dyspnea and huge blood loss. Added to this, there is the difficulty of the Amazon region, mostly on the riverside communities, which does not have a good emergency support in cases of this magnitude, needing to go to a specialized center, most of the time in Manaus to receive a proper care. So, considering infectious factors, prognosis was poor due to the late beginning of antibiotics and surgical cleaning of the wounds (on the third day after trauma), what makes this case even more relevant for its favorable outcome.
| References | |
| 1. | Vasconcelos WR. Genetic Diversity and Structure Population of Crocodilians Genetic Age and Structure Population of Crocodilians Jacaré-Açú (Melanosuchus niger) and Jacaré-Tinga (Caiman crocodilus) of the Amazon - Dissertation. Manaus - Amazonas National Research Institute of Amazonia.; 2005. p. 1-97.  |
| 2. | Langley RL. Alligator attacks on humans in the United States. Wilderness Environ Med 2005;16:119-24. |
| 3. | de Neto MC, Stolf H, Haddad Junior V. Alligator attack on fisherman in the Pantanal of Mato Grosso (Brazil): Case report Diagn Trat 2013;18:21-3. |
| 4. | Torralvo K, Botero-Arias R, Magnusson WE. Temporal variation in black-caiman-nest predation in Varzea of central Brazilian Amazonia. PLoS One 2017;12:e0183476. |
| 5. | Brook I. Management of human and animal bite wound infection: An overview. Curr Infect Dis Rep 2009;11:389-95. |
| 6. | Haddad V, Fonseca WC. Fatal attack on a child by a black caiman (Melanosuchus niger). Wilderness Environ Med 2011;22:62-4. |
| 7. | Sartain SE, Steele RW. An alligator bite. Clin Pediatr (Phila) 2009;48:564-7. |
| 8. | Doering EJ, Fitts CT, Rambo WM, Bradham GB. Alligator bite. JAMA 1971;218:255-6. |
| 9. | Erickson GM, Lappin AK, Parker T, Vliet KA. Comparison of bite-force performance between long-term captive and wild American alligators (Alligator mississippiensis). J Zool 2004;262:21-8. |
| 10. | Grubmüller M, Kerschbaum M, Diepold E, Angerpointner K, Nerlich M, Ernstberger A, et al. Severe thoracic trauma – Still an independent predictor for death in multiple injured patients? Scand J Trauma Resusc Emerg Med 2018;26:6. |
| Figures |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
Tension pneumothorax
| IMAGES IN CARDIOTHORACIC TRAUMA | |
|
The symptomless tension pneumothorax
Moheb A Rashid
Department of Surgery, Lillehammer Hospital, Lillehammer, Norway; Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
| Date of Web Publication | 20-Dec-2018 |
     |
Correspondence Address:
Moheb A Rashid
Department of Surgery, Lillehammer Hospital, Lillehammer; Scandinavian Cardiovascular Surgery Center, Gothenburg
 | Figure 1: This is a chest X-ray of a patient with symptomless right-sided tension pneumothorax, where the upper mediastinum (trachea) and lower mediastinum (heart) are shifted to the left side as shown in Figure 1. This phenomenon is unique; however, it does exist as in this patient, who came in a well-planned time to be checked up, 1 week after removal of a chest tube due to a right-sided pneumothorax. The patient was examined by the author after having the chest X-ray, and the patient denied any significant symptoms (no pain, no dyspnea, and normal respiration rate with stable vital signs). However, on examination, there was a slight tracheal shift to the left side which in turn is considered as a late sign in the course of tension pneumothorax development. Click here to view |
Cardiac herniation into pleural space and subcutaneous emphysema
Cardiac herniation into left pleural space and huge subcutaneous emphysema
Bruno José da Costa Medeiros
Surgery Institute of Amazonas' State, Manaus, Amazonas, Brazil
Bruno José da Costa Medeiros
Surgery Institute of Amazonas' State, Manaus, Amazonas, Brazil
A patient male, 45 years of age was brought to our trauma hospital after fall from a light pole (7 m of high), presenting shortness of breath and a huge subcutaneous emphysema. After the first assessment (oxygen supply and analgesia), the patient got better. He was transferred to imaging department; a computed tomography scan was performed. A huge subcutaneous emphysema surrounding the entire chest [Figure 1], a cardiac herniation into left pleural space [Figure 2] and a bilateral pneumothorax and right hemothorax were observed. The patient underwent bilateral blunt chest tube thoracostomy after that was transferred to cardiothoracic unit. He recovered well from the thoracotomy executed by cardiothoracic team.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
 | Figure 1: Huge subcutaneous emphysema surrounding the entire chest, small right hemothorax Click here to view |
 | Figure 2: Cardiac herniation into left pleural space, red arrow shows the right circumference of pericardial sac, blue arrow shows the heart herniated into pleural space Click here to view |
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Blunt thoracic aortic injury (BTAI)
REVIEW ARTICLE
Blunt thoracic aortic injury p. 11
Tara Talaie, Jonathan J Morrison, James V O'Connor
DOI:10.4103/jctt.jctt_7_18
Blunt thoracic aortic injury p. 11
Tara Talaie, Jonathan J Morrison, James V O'Connor
DOI:10.4103/jctt.jctt_7_18
Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.
http://www.jctt.org/currentissue.asp?sabs=y
http://www.jctt.org/currentissue.asp?sabs=y
the care of patients with rib fractures
the care of patients with rib fractures p. 5
Helen Ingoe, Catriona Mcdaid, William Eardley, Amar Rangan, Catherine Hewitt
DOI:10.4103/jctt.jctt_1_18
Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.
http://www.jctt.org/currentissue.asp?sabs=y
Helen Ingoe, Catriona Mcdaid, William Eardley, Amar Rangan, Catherine Hewitt
DOI:10.4103/jctt.jctt_1_18
Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.
http://www.jctt.org/currentissue.asp?sabs=y
Cardiothoracic Trauma
| EDITORIAL | ||
  | The First International Congress of the World Society for Cardiothoracic Trauma: Lessons learned | p. 1 |
| Moheb A Rashid DOI:10.4103/jctt.jctt_9_18 | ||
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| Controversies in cardiac trauma | p. 3 | |
| Kenneth L Mattox DOI:10.4103/jctt.jctt_7_17 | ||
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| ORIGINAL ARTICLES | | |
| A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures | p. 5 | |
| Helen Ingoe, Catriona Mcdaid, William Eardley, Amar Rangan, Catherine Hewitt DOI:10.4103/jctt.jctt_1_18 Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance. | ||
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| REVIEW ARTICLE | | |
 | Blunt thoracic aortic injury | p. 11 |
| Tara Talaie, Jonathan J Morrison, James V O'Connor DOI:10.4103/jctt.jctt_7_18 Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center. | ||
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| SURGICAL TECHNIQUES AND VIDEOS | | |
| Tension pneumothorax: Are current techniques and guidelines safe? | p. 19 | |
| Moheb A Rashid DOI:10.4103/jctt.jctt_5_18 | ||
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| CASE REPORTS | | |
 | When bleeding wins clotting: The surgical dilemma in life-threatening hemothorax in hemophilia | p. 20 |
| Nisha B Jain, Sreekar Balasundaram, Joseph Sushil Rao DOI:10.4103/jctt.jctt_2_18 Due to the lack of awareness and poor access to laboratory diagnosis, hemophilia may not be diagnosed preoperatively leading to therapeutic misadventure during surgery. Hence, this congenital bleeding disorder due to Factor VIII deficiency reduces surgical management. We report a 39-year-old gentleman, diagnosed of Factor VIII deficiency who presented to emergency with acute spontaneous left hemothorax and underwent a successful thoracotomy and decortication which saved his life. He is positive for human immunodeficiency virus as well as hepatitis B for which he is on treatment. The management guidelines for thoracic surgery are not addressed to in the World Federation of Hemophilia guidelines, making the management challenging in this scenario. We report this case due to its rarity and emphasize that early recognition with immediate surgical intervention supported with Factor VIII transfusion played an important role in saving life. | ||
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| Thoracic trauma by black caiman's bite in the Amazon region | p. 24 |
| João José Corrêa Bergamasco, Raquel Magalhães Pereira, Juan Eduardo Rios Rodriguez, Brígida Thaine Fernandes Cabral DOI:10.4103/jctt.jctt_3_18 Alligator attacks are rare, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. There are few reports of accidents by these animals. The reported species hereafter is the Melanosuchus niger from the Amazon rainforest. The patient aged 32 years, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite. Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite. Cases like this are not easy to conduct. Since the injury was on an atypical place, the severity of the symptoms was increased, leading to dyspnea and huge blood loss. | ||
| [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository]Beta | ||
| IMAGES IN CARDIOTHORACIC TRAUMA | | |
| The symptomless tension pneumothorax | p. 27 |
| Moheb A Rashid DOI:10.4103/jctt.jctt_6_18 | ||
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| Cardiac herniation into left pleural space and huge subcutaneous emphysema | p. 28 |
| Bruno José da Costa Medeiros DOI:10.4103/jctt.jctt_8_18 | ||
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Pre- and postadenotonsillectomy nocturnal enuresis in children with adenotonsillar hypertrophy
Pre- and postadenotonsillectomy nocturnal enuresis in children with adenotonsillar hypertrophy
Abdulhusein Mizhir Al-Maamuri
Department of ENT, Almahawil Hospital, Babil Health Directorate, Babylon Province, Iraq
Abdulhusein Mizhir Al-Maamuri
Department of ENT, Almahawil Hospital, Babil Health Directorate, Babylon Province, Iraq
Enuresis is a common health problem worldwide. It is estimated that there are over 50 million children with enuresis throughout the world. According to the International Children's Continence Society (ICCS), enuresis is intermittent incontinence while sleeping and it is a term applicable to children who are at least 5 years old.[1]
Enuresis may be classified as primary enuresis (80% of cases) – enuresis in a child who has never established urinary continence for more than 6 months – and secondary enuresis (20% of cases) – resumption of enuresis after at least 6 months of urinary continence.
Nocturnal enuresis (NE) means enuresis that occurs during sleep, daytime wetting means urinary incontinence that occurs while the child is awake, while monosymptomatic enuresis (uncomplicated) is enuresis without lower urinary tract symptoms other than nocturia and no history of bladder dysfunction.
Nonmonosymptomatic enuresis is the enuresis with lower urinary tract symptoms (e.g., increase or decrease in voiding frequency, daytime wetting, urgency, hesitancy, straining, weak or intermittent stream, posturination dribbling, holding maneuvers, sensation of incomplete emptying, and lower abdominal or genital discomfort).[1],[2]
NE is caused by a disparity between bladder capacity and nocturnal urine production and the child's failure to awaken in response to a full bladder. Factors associated with enuresis include nocturnal polyuria, detrusor instability, and an abnormally deep sleep pattern.[2]
There is no definite etiology for NE among children, and the disorder is probably multifactorial. Many potential causes have been suggested and investigated, such as dysfunction of sleep arousal, altered diurnal antidiuretic hormone secretion, genetic factors, nocturnal polyuria, psychological factors, delayed maturation, and parental age and education level.[3]
Sleep-disordered breathing (SDB) refers to a pathophysiologic continuum that includes snoring, upper airway resistance syndrome, obstructive hypopnea syndrome, and obstructive sleep apnea (OSA). Adenotonsillar hypertrophy (ATH) is the most common cause of SDB among children. Several retrospective studies have addressed the beneficial effects of AT in improving NE in children with simultaneous ATH.[4]
Although enuresis tends to disappear spontaneously as the child grows, a significant proportion of patients continue to wet the beds into adolescence or adulthood. The impact of enuresis on affected children and their families is mainly psychological and may be severe.[5] This makes treatment of prime importance.
This study was performed to screen the prevalence of NE among children who were already candidated for AT because of ATH and clinical features of SDB and compare it with a control group and also to investigate prospectively the beneficial effect of AT on NE in such children.
This is a descriptive study carried out in the ENT Department of Almahawil Hospital, Babylon Province, Iraq, from January 2014 to July 2017. In this study, we included 232 patients who were already decided to have AT operation because of ATH with upper airway obstruction (UAO). All these children had moderate-severe tonsillar enlargement (clinical Grades 3 and 4), adenoid hypertrophy confirmed by radiology, and clinical features of SDB such as mouth breathing, snoring, abnormal sleep position, and witnessed sleep apnea, and all had normal urine analysis.
For the purposes of this study, enuresis was defined as nighttime bedwetting to any degree in children aged 5 years and older and toilet trained. NE was defined in accordance with the ICCS standardized terminology.[1] Children with urinary incontinence associated with a well-known urological or neuro-urological dysfunction were excluded from the study. Hence, the type of all NE in our patients was primary and monosymptomatic.
The standardized tonsillar hypertrophy grading scale used was as follows:
Soft-tissue lateral neck radiography was done to confirm the adenoid hypertrophy, and urine analysis was made to detect any abnormalities. The age ranges between 5 and 16 years; 180 (78%) were 5–9 years and 52 (22%) from 10 to 16 years; and 128 were boys (55%) and 104 girls (45%). NE severity before operation was classified (mild – 1–2 nights/week, moderate – 3–4 nights/week, and severe – 5–7 nights/week). Patients were divided into two categories based on their enuresis response after AT operation: responders had a complete resolution or decreased enuresis episodes to < 2 nights (mild) a week and nonresponders had no change or 3 or more (moderate-severe) wet nights a week. We made a comparative study by comparing the association of (NE) in this group with a control group of the same number of patients (232) and the same age range (5–16 years) of both genders who visited our department for another complaint (other than ATH). We also follow the operated patients prospectively by recording the impact of AT operation on NE for 3–6 months postoperatively and compare the results with those who did not do the operation (for different reasons) for 3–6 months.
From a total of 232 patients with ATH, results found: 102 (44%) patients with NE, all were primary monosymptomatic type; 78 (63%) of them were 5–9 years of age, 24 (37%) in 10–16 years of age. Results also found that 130 (56%) of patients without NE. 102 (81%), of them were 5–9 years of age, and 28 (19%) 10–16 years of age. Regarding control group, from the total of 232, 21 (9%) of patients with NE: 16 (7%) of them were 5–9 years, and 5 (2%) 10–16 years [Figure 1].
Regarding the impact of AT on the 102 patients with NE [Figure 2], we could follow only 86 patients for 3–6 months postoperatively; The results were as follows: the responders: 32 (37%) of them showed complete resolution and 25 (29%) of them showed partial improvement, while the nonresponders: 29 (34%) of them showed no improvement. We could follow 36 (26%) of the 102 patients preoperatively for 3–6 months, and there was no change of their status of NE.
Enuresis is a frequent chronic illness in the pediatric population. Previous studies reported its frequency between 5% and 15%.[6]
Etiology of EN is still controversial. Delay of nervous system maturation, low bladder capacity, abnormalities of the urinary tract, inadequate secretion of antidiuretic hormone, genetic factors, immature waking mechanisms, deep sleep, neurologic bladder problems, bacteriuria, diet, socioeconomic status, and psychogenic factors were suggested as etiologic factors.[1]
The rate of EN in children with ATH and SDB has been reported to be between 20% and 34.5% in previous studies.[1]
In our study, the rate of NE in children with ATH and SDB was 44%, whereas it was 9% in the control group.
There are several hypotheses to explain the relationship between the ATH and the NE. Brooks and Topol believe that UAO has negative effects on arousal response.[6] Yeung et al. suggested that temporary fall in oxygen saturation in UAO patients leads to loss of bladder control. They indicated that a number of patients who could not be aroused before surgery were able to wake up and go to the bathroom after surgery.[7]
Besides this, upper airway resistance causes high inspiratory effort, and this effort results in high intrathoracic negative pressure that leads to cardiac distention, natriuretic response, and atrial natriuretic peptide secretion. As a result, atrial natriuretic peptide enhances natrium/water excretion and inhibits other hormones, which regulates fluid balance and the renin-angiotensin system.
Based on the results of our study, the post-AT cure rate and improvement rate of enuresis symptoms were 37% and 66%, respectively. Basha et al. investigated the effect of AT on NE and found an 84.2% improvement in enuresis symptoms after surgery.[8] Another study conducted by Weider et al. in 115 children with NE and OSA reported that enuresis symptoms were improved in 76% of patients after surgery.[4]
Limitations of this study are that we used subjective questions about symptoms such as NE which might not be accurate enough. We could not perform polysomnography for our patients, as it is the gold standard tool to assess the SDB, because of unavailability in our country. However, it is an expensive test and it is still controversial whether it is necessary to perform polysomnography as a routine preoperative test to document the presence of SDB in children with an obvious clinical situation.[9] Difficulty in the following of our patients and poor cooperation of some families is another limitation.
From this study, it can be concluded that children with ATH have a high rate of (NE). Adenotonsillectomy resulted in the complete resolution or partial improvement of NE in about two-thirds of patients.
Enuresis may be classified as primary enuresis (80% of cases) – enuresis in a child who has never established urinary continence for more than 6 months – and secondary enuresis (20% of cases) – resumption of enuresis after at least 6 months of urinary continence.
Nocturnal enuresis (NE) means enuresis that occurs during sleep, daytime wetting means urinary incontinence that occurs while the child is awake, while monosymptomatic enuresis (uncomplicated) is enuresis without lower urinary tract symptoms other than nocturia and no history of bladder dysfunction.
Nonmonosymptomatic enuresis is the enuresis with lower urinary tract symptoms (e.g., increase or decrease in voiding frequency, daytime wetting, urgency, hesitancy, straining, weak or intermittent stream, posturination dribbling, holding maneuvers, sensation of incomplete emptying, and lower abdominal or genital discomfort).[1],[2]
NE is caused by a disparity between bladder capacity and nocturnal urine production and the child's failure to awaken in response to a full bladder. Factors associated with enuresis include nocturnal polyuria, detrusor instability, and an abnormally deep sleep pattern.[2]
There is no definite etiology for NE among children, and the disorder is probably multifactorial. Many potential causes have been suggested and investigated, such as dysfunction of sleep arousal, altered diurnal antidiuretic hormone secretion, genetic factors, nocturnal polyuria, psychological factors, delayed maturation, and parental age and education level.[3]
Sleep-disordered breathing (SDB) refers to a pathophysiologic continuum that includes snoring, upper airway resistance syndrome, obstructive hypopnea syndrome, and obstructive sleep apnea (OSA). Adenotonsillar hypertrophy (ATH) is the most common cause of SDB among children. Several retrospective studies have addressed the beneficial effects of AT in improving NE in children with simultaneous ATH.[4]
Although enuresis tends to disappear spontaneously as the child grows, a significant proportion of patients continue to wet the beds into adolescence or adulthood. The impact of enuresis on affected children and their families is mainly psychological and may be severe.[5] This makes treatment of prime importance.
This study was performed to screen the prevalence of NE among children who were already candidated for AT because of ATH and clinical features of SDB and compare it with a control group and also to investigate prospectively the beneficial effect of AT on NE in such children.
This is a descriptive study carried out in the ENT Department of Almahawil Hospital, Babylon Province, Iraq, from January 2014 to July 2017. In this study, we included 232 patients who were already decided to have AT operation because of ATH with upper airway obstruction (UAO). All these children had moderate-severe tonsillar enlargement (clinical Grades 3 and 4), adenoid hypertrophy confirmed by radiology, and clinical features of SDB such as mouth breathing, snoring, abnormal sleep position, and witnessed sleep apnea, and all had normal urine analysis.
For the purposes of this study, enuresis was defined as nighttime bedwetting to any degree in children aged 5 years and older and toilet trained. NE was defined in accordance with the ICCS standardized terminology.[1] Children with urinary incontinence associated with a well-known urological or neuro-urological dysfunction were excluded from the study. Hence, the type of all NE in our patients was primary and monosymptomatic.
The standardized tonsillar hypertrophy grading scale used was as follows:
- Grade 0 – Tonsils are entirely within the tonsillar fossa
- Grade 1 – Tonsils occupy <25% of the lateral dimension of the oropharynx, as measured between the anterior tonsillar pillars
- Grade 2 – Tonsils occupy <50% of the lateral dimension of the oropharynx
- Grade 3 – Tonsils occupy <75% of the lateral dimension of the oropharynx
- Grade 4 – Tonsils occupy 75% or more of the lateral dimension of the oropharynx.
Soft-tissue lateral neck radiography was done to confirm the adenoid hypertrophy, and urine analysis was made to detect any abnormalities. The age ranges between 5 and 16 years; 180 (78%) were 5–9 years and 52 (22%) from 10 to 16 years; and 128 were boys (55%) and 104 girls (45%). NE severity before operation was classified (mild – 1–2 nights/week, moderate – 3–4 nights/week, and severe – 5–7 nights/week). Patients were divided into two categories based on their enuresis response after AT operation: responders had a complete resolution or decreased enuresis episodes to < 2 nights (mild) a week and nonresponders had no change or 3 or more (moderate-severe) wet nights a week. We made a comparative study by comparing the association of (NE) in this group with a control group of the same number of patients (232) and the same age range (5–16 years) of both genders who visited our department for another complaint (other than ATH). We also follow the operated patients prospectively by recording the impact of AT operation on NE for 3–6 months postoperatively and compare the results with those who did not do the operation (for different reasons) for 3–6 months.
From a total of 232 patients with ATH, results found: 102 (44%) patients with NE, all were primary monosymptomatic type; 78 (63%) of them were 5–9 years of age, 24 (37%) in 10–16 years of age. Results also found that 130 (56%) of patients without NE. 102 (81%), of them were 5–9 years of age, and 28 (19%) 10–16 years of age. Regarding control group, from the total of 232, 21 (9%) of patients with NE: 16 (7%) of them were 5–9 years, and 5 (2%) 10–16 years [Figure 1].
 | Figure 1: Distribution of the patients according to the age Click here to view |
Regarding the impact of AT on the 102 patients with NE [Figure 2], we could follow only 86 patients for 3–6 months postoperatively; The results were as follows: the responders: 32 (37%) of them showed complete resolution and 25 (29%) of them showed partial improvement, while the nonresponders: 29 (34%) of them showed no improvement. We could follow 36 (26%) of the 102 patients preoperatively for 3–6 months, and there was no change of their status of NE.
 | Figure 2: Impact of adenotonsillar hypertrophy on the patients with nocturnal enuresis Click here to view |
Enuresis is a frequent chronic illness in the pediatric population. Previous studies reported its frequency between 5% and 15%.[6]
Etiology of EN is still controversial. Delay of nervous system maturation, low bladder capacity, abnormalities of the urinary tract, inadequate secretion of antidiuretic hormone, genetic factors, immature waking mechanisms, deep sleep, neurologic bladder problems, bacteriuria, diet, socioeconomic status, and psychogenic factors were suggested as etiologic factors.[1]
The rate of EN in children with ATH and SDB has been reported to be between 20% and 34.5% in previous studies.[1]
In our study, the rate of NE in children with ATH and SDB was 44%, whereas it was 9% in the control group.
There are several hypotheses to explain the relationship between the ATH and the NE. Brooks and Topol believe that UAO has negative effects on arousal response.[6] Yeung et al. suggested that temporary fall in oxygen saturation in UAO patients leads to loss of bladder control. They indicated that a number of patients who could not be aroused before surgery were able to wake up and go to the bathroom after surgery.[7]
Besides this, upper airway resistance causes high inspiratory effort, and this effort results in high intrathoracic negative pressure that leads to cardiac distention, natriuretic response, and atrial natriuretic peptide secretion. As a result, atrial natriuretic peptide enhances natrium/water excretion and inhibits other hormones, which regulates fluid balance and the renin-angiotensin system.
Based on the results of our study, the post-AT cure rate and improvement rate of enuresis symptoms were 37% and 66%, respectively. Basha et al. investigated the effect of AT on NE and found an 84.2% improvement in enuresis symptoms after surgery.[8] Another study conducted by Weider et al. in 115 children with NE and OSA reported that enuresis symptoms were improved in 76% of patients after surgery.[4]
Limitations of this study are that we used subjective questions about symptoms such as NE which might not be accurate enough. We could not perform polysomnography for our patients, as it is the gold standard tool to assess the SDB, because of unavailability in our country. However, it is an expensive test and it is still controversial whether it is necessary to perform polysomnography as a routine preoperative test to document the presence of SDB in children with an obvious clinical situation.[9] Difficulty in the following of our patients and poor cooperation of some families is another limitation.
From this study, it can be concluded that children with ATH have a high rate of (NE). Adenotonsillectomy resulted in the complete resolution or partial improvement of NE in about two-thirds of patients.
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This is the fourth in a series of posts based upon Jordan Peterson's book Maps of Meaning, published in 1999 after 17 years of researc...
