To identify patients in whom damage control surgical procedures alone were not sufficient to achieve acceptable mortality rates.Methods: Hospital charts of trauma patients from October, 2004 to March, 2007, analyzed by: trauma severity indices, hemoglobin level, pH, PaO2, and bicarbonate level. Kruskal Wallis test and multiple comparison tests based on Z value (p ≤ 0.05).Results: 37 patients were study. Mean age 34.7 ± 16.3 years (89% male). Blunt trauma was the most frequent (84%). They were divided into three groups according with death: Group I: mortality <24 h (n = 17), Group II: mortality >24 h (n = 5), and Group III: survivors (n = 15).Prognostic variable by groupRTS I: 4.22 ± 2.39, II 5.22 ± 2.46; III: 7.17 ± 0.85 p = 0.0005. ____ISS I: 35.71 ± 11.05; II: 25.80 ± 11.08; III: 24.87 ± 10.55 p = 0.0268. ____TRISS I: 46.98 ± 35.40 II: 71.20 ± 35.54; III: 90.05 ± 20.56 p = 0.0004____GCS: I: 6.71 ± 4.37; II: 7.60 ± 6.31; III: 12.73 ± 2.81; p = 0.0017____Hemoglobin I 7.44 ± 3.80; II: 9.25 ± 3.54; III: 9.02 ± 3.36 p = 0.7555____pH: I: 6.96 ± 0.09; II: 7.10 ± 0.10; III: 7.15 ± 0.14 p = 0.0425____PaO2: I: 159.33 ± 58.35; II: 140.75 ± 82.40; III: 244.39 ± 92.39 p = 0.0231____Bicarbonate: I: 9.55 ± 0.98; II: 16.70 ± 2.28; III: 15.70 ± 4.32 p = 0.0045Patients who died <24 h presented higher injury severity scores RTS, ISS, TRISS, Glasgow Coma Scale, and more severe metabolic disturbances than survivors. Among patients who survived at least 24 h, control of bleeding and of metabolic disturbances was effective in 95% of cases (only one death due to hemorrhage).Conclusion: severity indices and metabolic changes seem to correlate with the outcome of severe trauma patients subjected to surgical damage control procedures.

Pulmonaryarterypseudo-aneurysm(PAPA)resultingfromchesttrauma is uncommon. Seventeen cases have been described in theliterature [1–17]: 12 of these resulted from penetrating injuries[1,2,4,5,7,8,12,13,15–17], 4 from blunt injuries [3,9,11,14],and1case that involved penetrating chest trauma with simultaneouspulmonary artery and pulmonary vein pseudo-aneurysm [10].In 2006, Reade et al. first described the case of blunt traumaticmain PAPA, detected on initial computed tomography (CT) scan,that was treated non-operatively [14]. In every reported case, thetraumatic PAPA was repaired operatively by means of localresection (aneurysectomy), ligation of vessels, lobectomy orembolisation [5,15].The development and improvement of imaging techniques,especiallymultisliceCT scan,havepermittedthediagnosis of‘newinjuries’ in trauma patients. These injuries identified with moderndiagnostic technology may represent a challenge to the surgeon,who has to determine or characterise their nature and apply theappropriate management.Here,wereporttwocasesofpulmonaryvesselpseudo-aneurysmin blunt-trauma patients who were admitted to our emergencysurgical service (ESS) and were successful treated non-operatively.1. Case 1A 37-year-old man was involved in a collision with a car whileriding a bicycle and arrived at our ESS without any additionalinformation. The patient was not alert upon his admission to theemergency room. An orotracheal intubation was performed. Thechest physical examination showed multiple thoraco-abdominalexcoriations, and bilateral vesicular murmur was present withdiffuse bruises. The cardiocirculatory system was normal onphysical examination, and the focussed assessment with sono-graphy for trauma (FAST) showed fluid in hepatorenal and pelvicfields.Pelvicandrectalexaminationwasnormal,andtheurinewasclear. The Glasgow Coma Scale (GCS) score was 8 before sedation.Right tibia and fibula fractures (Gustilo grade IIIa) were observed.Acranial/thoracicCTscanshowedmultiplefacialfractures(nasal,maxillary, right zygomatic and bilateral orbital), as well as a smallright haemo-pneumothorax, a right PAPA measuring 24 mm 21mm 23mm (23-mm extension) and a right inferior pulmonaryvein pseudo-aneurysm measuring 10 mm (Fig. 1). An abdominal/pelvicCTshowedasmallrighthepaticlobelaceration,arightadrenalhaematomaand smallliquid collectionsinhepatic andpelvic fields.The patient underwent external fixation of tibia and fibulafractures performed by the orthopaedic surgery group. Facialfractures as well as the thoracic and abdominal lesions weremanaged non-operatively. The patient received care in the traumaintensive care unit (ICU), where he required continuous nora-drenalininfusionfor3days.Eightdaysafteradmission,thepatienthad internal fixation of tibia and fibula fractures. No specifictreatmentforthepseudo-aneurysmwasperformed.A repeatedCTscan performed 22 days after admission showed no evidence ofpseudo-aneurysm of pulmonary artery or vein. The patient’scondition improved rapidly, and the patient was discharged fromthe hospital 23 days after admission.2. Case 2A70-year-oldmanwasinvolvedinvehiclecrashwithapole.Theaccidentsiteassessmentrevealedthathewasnotwearingaseatbelt.Hislevelofconsciousnesswasunknown.Intheemergencyroom,hepresented with wheezing; chest examination showed paradoxicalmovementsoftherighthemithoraxwithinstabilityofchestwallandreducedhomolateralvesicularmurmurs.Orotrachealintubationandright chest drainage were performed. His heart rate was 74 beats/min,hisbloodpressurewas116/78 mmHgandhisheartsoundswerenormal on auscultation. His GCS score was 15 and no additionalinjurieswereobserved.TheFASTshowednofluidaccumulation.TheCTscanexaminationwithcontrastshowednosignofinjurytoheador

Asymptomatic tumors are not uncommon, may be diagnosed during clinical examination or during surgical interventions for other purposes such as treatment of a hemorrhage due a blunt trauma.Case report 6 year‐old boy had fallen, hitting his abdomen against a rock, and arrived at hospital ten hours later. Initial assessment he was complaining of diffuse abdominal pain; his physical examination showed: respiratory rate: 16 mov/min, blood pressure: 100 × 80 mmHg, heart rate: 100 bat/min, and Glasgow coma score: 15. His abdomen was distended, with guarding and rebound tenderness, and had a palpable mass. FAST ultrasound was positive; and Ct‐scan showed an abdominal mass with 15 × 12 × 7 cm dimension, and moderate amount of free blood in the abdominal cavity. Laboratory tests showed: hemoglobin 9.9 mg/dl, hematocritic 28.8%, white blood cells 6.900 cel/dl.Midline laparotomy was performed, a large, injured and bleeding mesenteric mass was found encircling superior mesentery artery and several small bowel loops; 500 ml of free blood was found in the peritoneal cavity. Mesenteric mass was partially removed with a segment of the small bowel. Findings of anatomico‐pathologic examination revealed an intestinal Burkitt lymphoma, with mesenteric linfonodes. Patient had an uneventful postoperative course, and started with quimotherapy.Comments This case report shows an unusual traumatic abdominal blending that could not be clearly diagnosed before laparotomy was performed. The emergency of this case was bleeding control, decision to remove mass was taken only for this purpose, and not to treat the tumor. As removal of the whole mass was impossible, a partial removal was performed.

Although uncommon, and despite the modern in diagnostic tools and therapeutic alternatives, retrohepatic and main hepatic veins injury remains associated with high mortality rate. Preoperative diagnosis is uncommon, and bullet trajectory may be a helpful sign in penetrating trauma patients.Patients and Methods Hospital records of patients sustaining retroheptic vena cava (RHVC) injury were retrospectively reviewed as to diagnosis, associated injuries, injury characteristics, surgical management, and outcome, last ten years.Results Eight male, 17 to 45 (mean 27.5) years‐old patients sustaining RHVC injury were reviewed. Mean trauma indexes for the 8 cases were: ISS 36.6, RTS 7.55 and TRISS 89.0; and for the group who died: ISS 41.6, RTS 7.18, and TRISS 80.5. Two patients had sustained blunt trauma (one died), and six had penetrating injuries (two died). The injury diagnosis was achieved during surgery in all cases. A transfixing RHV injury occurred in 4 (50% of the) patients, and was found in all the 3 patients who died. An atriocaval shunt was employed in four patients, 3 of them had with transfixing injury with two deaths. The number of associated injuries was higher in the patients who died. Overall mortality rate was 37.5%.Comments Despite advances in image diagnosis, injuries to RHVC are frequently diagnosed during surgery. Tangential injuries were managed with direct approach and sutures, and to control blending in transfixing injuries, were managed with atriocaval shunts, before suture.Conclusion Despite improvements in its diagnosis and management, RHVC injuries remain with a high mortality rate, mainly when transfixing, and associated with numerous associated injuries.