Kanama, travma ile iliþkili ölümlerin baþta gelen nedenidir. Kanamanýn erken tanýsý ve cerrahi kontrolü, travmalý hastanýn tedavisinin düzenlenmesinde kritik ilk adýmdýr; ne var ki bu amaca ulaþmak, ileri derecede kritik travma hastalarýnda hala ciddi bir sorun olagelmektedir. Geleneksel cerrahi kanama kontrolü yöntemlerine ek olarak, günümüzde bazý ileri hemostatik ajanlar da kullanýlmaktadýr. Oksidize selüloz, fibrin yapýþtýrýcý ile sentetik yapýþtýrýcýlar, lokal hemostatik ajanlarýn öncelikli grubunu oluþturmaktadýr. Zeolite ve Chitosan, lokal hemostatiklerin en yeni jenerasyonunu oluþturur ve bu ajanlarýn etkinliði ve güvenilirliði halen araþtýrma aþamasýndadýr. Rekombinant faktör VIIa yakýn zamanda, kontrol altýna alýnamayan cerrahi kanamanýn tedavisine yardýmcý, ümit verici bir sistemik hemostatik ajan olarak ortaya çýkmýþtýr; ancak devam eden çok uluslu randomize kontrollü çalýþma tamamlanýncaya kadar rekombinant faktör VIIa’nýn travma hastalarýndaki kullanýmý ile ilgili endikasyonlar ve güvenilirlik profili belirsizdir. Bu yazýda, ticari olarak mevcut bulunan lokal ve sistemik hemostatik ürünlerin travma hastalarýndaki rolü gözden geçirildi; ayný zamanda bunlarýn akýlcý kullanýmýyla ilgili benzersiz özelliklerle endikasyon ve kýsýtlamalar deðerlendirildi.

Hemorrhage is the leading cause of trauma-related deaths. The early identification and surgical control of this hemorrhage is the crucial first step in the management of the injured patient; however, this objective remains challenging in the most critically ill trauma patients. As an adjunct to traditional methods of surgical hemorrhage control, several advanced hemostatic agents are currently available. Oxidized cellulose, fibrin glue and synthetic adhesives constitute the first-line of local hemostatic agents. Materials such as Zeolite and Chitosan comprise the newest generation of local hemostatics and the efficacy and safety of these agents are currently under investigation. Recombinant factor VIIa has emerged recently as a promising systemic hemostatic adjunct for the treatment of intractable surgical bleeding; however, until completion of the ongoing multinational randomized control trial, the indications for its use in trauma patients and its safety profile are unclear. This article reviews the role of commercially available local and systemic hemostatic products in the trauma patient population; it also addresses the unique set of characteristics, indications, limitations and rationale for their use.

AMAÇ: Bu çalýþmada, iloprost ve pentoksifilinin tavþan iskelet kasýnda iskemi reperfüzyon (IR) hasarý üzerine etkileri araþtýrýldý. GEREÇ-YÖNTEM: Kýrk adet Yeni Zelanda cinsi beyaz tavþan her grupta 10 adet olacak þekilde dört gruba ayrýldý. Grup 1’de iloprost iki saat abdominal aort ve iliyak dallarýnýn klemplenmesiyle oluþturulan iskemiyi takiben dört saatlik reperfüzyon boyunca infüzyon olarak verildi. Grup 2’ye pentoksifilin, Grup 3’e ise serum fizyolojik verildi. Grup 4 sham grubu idi. Gastroknemyus kasýndan malondialdehit düzeyi ve mikroskopik ödem skoru incelendi. BULGULAR: Grup 1’de kontrol grubuna göre mikroskoppik ödem skorlamasýnda anlamlý bir düþüklük saptandý (Grup 1 vs Grup 3, p=0,040; Grup 2 vs Grup 3, p=0,145; Grup 1 vs Grup 2, p=0,580). Malondialdehit düzeyleri bakýmýndan Grup 1 ve Grup 2’de kontrol grubuna kýyasla anlamlý bir düþüklük saptandý (Grup 1: 60±11 nmol/gr, Grup 2: 74±11 nmol/gr, Grup 3: 95±10 nmol/gr, Grup 4: 29±7 nmol/gr) (Grup 1 vs Grup 2, p=0,010; Grup 1 vs Grup 3, p<0,001; Grup 2 vs Grup 3, p<0,001; Grup 1 vs Grup 4, p<0,001; Grup 2 vs Grup 4, p<0,001; Grup 3 vs Grup 4: p<0,001). SONUÇ: Ýskelet kasý akut iskemisi sýk bir klinik sorundur, erken dönemde iloprost ve pentoksifilin tedavisinin IR hasarýný azaltabileceði görüþündeyiz.

BACKGROUND: We investigated the effects of iloprost and pentoxifylline on skeletal muscle ischemia-reperfusion injury in a rabbit model. METHODS: Forty New Zealand white rabbits were grouped into four. In Group 1, iloprost was continuously infused starting half an hour before the reperfusion following a 2-hour ischemia formed by abdominal aortic occlusion, and it was continued during the 4-hour reperfusion period. Group 2 was treated with pentoxifylline, and Group 3 received saline solution. Group 4 was the sham group. Malondialdehyde levels and edema scores in gastrocnemius muscle were evaluated. RESULTS: Edema score was significantly lower in Group 1 when compared with the control group (Group 1 vs Group 3, p=0.040; Group 2 vs Group 3, p=0.145; Group 1 vs Group 2, p=0.580). Malondialdehyde levels of the medicated groups were significantly lower when compared with the control group (Group 1: 60±11 nmol/g tissue, Group 2: 74±11 nmol/g tissue, Group 3: 95±10 nmol/g tissue; Group 1 vs Group 2, p=0.010; Group 1 vs Group 3, p<0.001; Group 2 vs Group 3, p<0.001; Group 1 vs Group 4, p<0.001; Group 2 vs Group 4, p<0.001; Group 3 vs Group 4: p<0.001).
CONCLUSION: Acute skeletal muscle ischemia is a common problem. We are of the opinion that in the early phase of skeletal muscle ischemia, iloprost and pentoxifylline medication may reduce ischemia-reperfusion injury.

AMAÇ: Sýçanlarda deneysel olarak oluþturulan karýniçi yapýþýklýklarýn önlenmesinde topikal olarak uygulanan metilprednizolonun farklý dozlarýnýn etkinliði deðerlendirildi.
GEREÇ-YÖNTEM: Çalýþmada 40 adet diþi Wistar cinsi sýçan kullanýldý. Sýçanlar, yüksek doz steroid, düþük doz steroid, serum fizyolojik ve kontrol grubu olmak üzere dört gruba ayrýldý. Tüm sýçanlara yapýlan median laparotomi ve yapýþýklýk oluþturulmasýný takiben yüksek doz steroid uygulanan sýçan grubuna 16 mg/kg, düþük doz steroid grubuna 10 mg/kg metilprednizolon, serum fizyolojik grubuna da serum fizyolojik topikal olarak periton içine uygulandý. Son gruba ise ek bir uygulama yapýlmadý. Sýçanlar 15. gün öldürüldü, karýniçi yapýþýklýklar Linsky skalasýna göre deðerlendirildi.
BULGULAR: Gruplar arasýnda yapýþýklýk þiddeti (p=0,867), yapýþýklýk derecesi (p=0,919), katýlým yüzdesi (p=0,876) ve toplam skor (p=0,574) puanlarý açýsýndan karþýlaþtýrma yapýldýðýnda istatistiksel bir fark bulunmadý. Yara enfeksiyonu açýsýndan da anlamlý bir fark yoktu (p>0,05). SONUÇ: Topikal olarak uygulanan metilprednizolonun farklý dozlarýnýn, karýniçi yapýþýklýklarýn önlenmesindeki etkinlikleri arasýnda anlamlý fark bulunmadýðý gibi, yapýþýklýklarýn azaltýlmasý üzerine de bir etkisi yoktur.

BACKGROUND: To assess the effectiveness of different doses of methylprednisolone on preventing intraabdominal adhesions established experimentally in rats.
METHODS: Forty female Wistar rats were divided into four groups: high-dose steroid (16 mg/kg), low-dose steroid (10 mg/kg), serum physiologic, and control. Following median laparotomy and procedure for adhesion formation in all rats, 16 mg/kg methylprednisolone (high-dose steroid group), 10 mg/kg methylprednisolone (low-dose steroid group), or serum physiologic (serum physiologic group) was administered into the intraperitoneal space, topically. No additional procedure was applied to rats in Group 4 (Control). All rats were sacrificed on day 15 postoperatively, and intraperitoneal adhesions were assessed according to Linsky’s scale. RESULTS: No significant differences were determined between the groups with respect to severity (p=0.867), degree (p=0.919), extent (p=0.876), and general scores (p=0.574) of adhesion formation. Wound infection rates were also similar in the four groups (p>0.05). CONCLUSION: There was no difference in the effectiveness of different methylprednisolone doses, administered topically, in preventing intraabdominal adhesion formation, and furthermore, steroids do not prevent intraabdominal adhesion development.

AMAÇ: Torakal ve abdominal aortanýn anevrizma rüptürü ve diseksiyon gibi acil patolojileri önemli derecede yaþamý tehdit ederler. Aortanýn acil giriþim gerektiren bu patolojilerinde endovasküler tedaviler konvansiyonel cerrahiye bir alternatif teþkil etmektedir. Çalýþmada, endovasküler tedavilerin aortanýn acil patolojilerindeki uygulanabilirliði araþtýrýldý. GEREÇ-YÖNTEM: Nisan 2004 ile Mart 2007 tarihleri arasýnda 16 hastaya (13 erkek, 3 kadýn; ort. yaþ 61,4±16,3; daðýlým 38-86) acil olarak endovasküler yolla stent greft implantasyonu uygulandý. Lezyonlarýn sekizi torakal, sekizi abdominal aortada idi. Sekiz hastaya Gore Excluder Endoprosthesis, sekiz hastaya MedtronicVascular Talent Endoluminal Graft System kullanýldý. BULGULAR: Tüm hastalara implantasyon baþarý ile uygulandý, hiçbir hastada açýk cerrahiye dönüþüme ihtiyaç duyulmadý. Hastane mortalitesi üç hasta olarak gerçekleþti, üç hastada (%18,75) endoleak ile karþýlaþýldý. SONUÇ: Anevrizma ya da diseksiyon gibi acil giriþim gerektiren aort patolojilerinde ameliyat öncesi ve sonrasý morbidite ve mortalitenin düþük olmasý nedeniyle endovasküler stent implantasyonu efektif ve teknik olarak uygulanabilirliði yüksek olan bir yöntemdir.

BACKGROUND: Emergent situations of both the thoracic and abdominal aortae are serious life-threatening situations. Endovascular stent graft repair offers an alternative to conventional operation for management of aortic diseases. Our aim was to report our experience with endovascular stent graft repair of thoracic and abdominal aortic emergencies. METHODS: Between April 2004 and March 2007, endovascular stent graft repair was performed in 16 patients (13 males, 3 females; mean age 61.4±16.3; range 38 to 86 years). The emergent lesions were in the thoracic aorta in 8 patients and abdominal aorta in the remainder. The deployed stent graft systems were Talent-Medtronic (n=8) and Excluder-Gore (n=8). RESULTS: Successful deployment of the stent grafts in the appropriate position was achieved in all patients. Hospital mortality occurred in 3 patients. There was no conversion to open surgery. The total number of endoleaks was 3 (18.75%). CONCLUSION: Endovascular stent graft placement is a feasible and effective approach in the emergency treatment of patients with complicated emergent pathologies of both thoracic and abdominal aortae.

AMAÇ: Paraþütçülük, spor ve mesleki amaçla yapýlan, kontrollü fiziksel hareketlilik ve güç gerektiren bir aktivitedir. Paraþütçülüðe olan ilginin artmasýyla birlikte acil servislerde görülen yaralanma oranlarý da artmaktadýr. Bu nedenle, çalýþmamýzda paraþütle oluþan yaralanma mekanizmalarý ve özelliklerini araþtýrmayý amaçladýk. GEREÇ-YÖNTEM: Paraþütle atlama sýrasýnda yaralanarak acil servise getirilen olgularýn yaþ ortalamasý, travmaya maruz kalan vücut bölgeleri, kesin tanýlarý, uygulanan tedavi yöntemleri, hastaneye yatýþ veya taburculuklarý gibi parametreleri hazýrlanan forma prospektif olarak kaydedildi. Hastalarýn yaralanmalarýnýn þiddeti kýsaltýlmýþ yaralanma ölçeði (AIS), yaralanma þiddeti ölçeði (ISS) deðerlendirilerek analiz edildi. BULGULAR: Hastalarýn ortalama ISS’si 8,15±4,29 olarak saptandý. Yaralanmaya en sýk maruz kalan vücut bölgesi ekstremitelerdi. Ekstremite yaralanmalarýnýn 13’ünde (%81) alt ekstremite, 3’ünde (%19) üst ekstremite etkilenmiþti. Alt ekstremite yaralanmalarýnda en fazla yaralanan bölge ise %47’lik oranla ayak bileði bulundu. Ekstremite yaralanmalarýný kafa yaralanmalarýnýn izlediði saptandý. SONUÇ: Paraþütle atlama sonucu oluþan yaralanmalar çoðunlukla yere iniþte dengenin kaybedilmesi ile ortaya çýkmaktadýr. Dengenin kaybedilmesinde rüzgarýn yön deðiþtirmesi gibi doðal olaylar veya kiþisel nedenlerin etkili olduðu görülmüþtür. Paraþütle atlama ve iniþ tekniðinin fazlarý hakkýnda yeterli bilgi birikiminin olmasý ile yaralanma olasýlýðý azalacaktýr.

BACKGROUND: Parachuting is performed for sportive and occupational purposes and demands a high level of controlled physical performance. In conjunction with the growing interest in parachuting, injury rates in the emergency departments are also increasing. We thus aimed to evaluate the mechanism and characteristics of injuries due to parachuting. METHODS: Parameters of the patients injured and presenting to the emergency department, including mean age, body area exposed to injury, definite diagnosis, applied treatment modalities, and admission to/discharge from the hospital, were all recorded in a previously prepared form and analyzed. Degree of injury was detected by calculating the Injury Severity Score (ISS) using the Abbreviated Injury Scale (AIS). RESULTS: Mean ISS of the patients was 8.15±4.29. The most commonly affected body sites were the extremities. Of the extremity injuries, 13 (81%) involved lower extremities and 3 (19%) involved upper extremities. The most commonly affected site in the lower extremities was the ankle (47%). Head injuries followed extremity injuries as the second most affected site. CONCLUSION: Injuries from parachute jumping mostly occur during landing due to loss of balance. Loss of balance was seen to result from change in wind direction and personal factors. When jumpers acquire adequate knowledge about phases of parachute jumping and landing, probability of injury will decrease.

AMAÇ: Bu çalýþmada künt karýn travmasý (KKT) ile baþvuran hastalarda uygulanan tanýsal testlerin ortaya konulmasý ve bunlarýn cerrahýn kararlarý üzerine olan etkilerinin incelenmesi amaçlanmýþtýr. GEREÇ-YÖNTEM: GÜTF'ne Mayýs 2003-Mayýs 2005 tarihleri arasýnda KKT nedeniyle baþvuran 144 hasta retrospektif olarak incelendi.Hastalar yaþ, cinsiyet, yaralanma mekanizmasý, Glasgow koma skalasý,revise edilmiþ travma skoru,izlem periodu, uygulanan tanýsal testler ve tedavi yöntemleri açýsýndan deðerlendirildi. BULGULAR: Hastalarýn 98’i erkek ve 46’sý kadýn olup ortalama yaþlarý 36yaþ(17-84yaþ) olarak bulundu. Travma nedeni 126(% 87.5)hastada trafik kazasý,14(%9.7) hastada yüksekten düþme,4(%2.8) hastada ise darp olarak tesbit edildi.Hastalarýn 21’inde izole karýn travmasý, 123’ünde ise çoklu sistem travmasý mevcuttu.Hastalarýn 139’una(%97) abdominal ultrasonografi ve 73’üne(%51) abdominal tomografi uygulandý. Diagnostik peritoneal lavaj (DPL) 41(%28.4) hastaya yapýldý ve 15’inde(%37) pozitif olarak deðerlendirildi. 19 hastaya(%13.2) acil laparatomi yapýlýrken;abdominal ultrasonogrofi ve tomografide serbest sývý bulunan ve hemodinamik olarak stabil olan 21 hasta takibe alýndý.Bu hastalardan 2’sine takip esnasýnda laparatomi kararý alýndý ve operasyonda intestinal perforasyon saptandý. Genel mortalite %16,cerrahi uygulanan vakalarda ise mortalite %14.3 olarak bulundu.
SONUÇ: Ultrasonografi,abdominal tomografi ve DPL birbirinin alternatifi olan tetkikler olarak görülmemelidir.Bu tetkikler bir bütünün tamamlayýcýlarý olarak kullanýldýðýnda, künt karýn travmasýna sekonder solid organ yaralanmasý olan bir çok hasta opere edilmeksizin izlenebilecektir. Böylece gereksiz laparotomiler ve bunlarýn neden olacaðý mortalite ve morbiditeler önlenmiþ olacaktýr.

BACKGROUND: In the present study, it is intended to outline the diagnostic tests and their influences on decisions of the surgeon about patients presented with blunt abdominal trauma. METHODS: One hundred forty-four patients (98 males, 46 females; mean age 36; range 17 to 84 years) admitted to Gazi Universty School of Medicine due to blunt abdominal trauma (BAT) between May 2003-May 2005 were reviewed retrospectively. Age, gender, injury mechanism, Glasgow Coma Scale, revised trauma score, follow-up period, applied diagnostic procedures, and treatment methods were evaluated. RESULTS: The underlying cause was traffic accident in 126 (87.5%) patients, fall from height in 14 (9.7%) patients, and blows in 4 (2.8%) patients. Isolated abdominal trauma was seen in 21 patients and multisystem trauma in 123 patients. The most frequent associated trauma was head injury (66.6%). Abdominal ultrasonography (USG) was applied in 139 (97%) of the patients, and abdominal computed tomography (CT) was performed in 73 (51%). Diagnostic peritoneal lavage (DPL) was applied in 41 (28%) patients, and 15 (37%) of them proved to be positive. While emergency laparotomy was applied in 19 (13.2%) of the patients, 21 hemodynamically stable patients were diagnosed to have free fluid through USG and CT and were followed-up. During the follow-up period, 2 patients were scheduled to be operated, and small intestine perforation was found in these patients. The overall mortality rate for all patients was 16%, and the postoperative mortality rate with respect to the operated patients was 14.3%. CONCLUSION: If USG, CT, and DPL are applied in a complementary manner, a large number of patients with solid organ injuries secondary to blunt trauma can be managed nonoperatively. Thus, unnecessary laparotomies can be avoided and related morbidities and mortalities decreased.

AMAÇ: Çocukluk çaðýnda spontan koledok perforasyonu (SKP) oldukça ender görülen bir akut karýn nedenidir. Etyolojide pankreatobiliyer baðlantý anomalisi sorumlu görülmektedir. Çalýþmada, yaygýn peritonitle seyreden cerrahi patolojiler arasýnda öncelikle akla gelen perfore apandisitten farklý bir yaklaþým gerektiren SKP’nin taný ve tedavisinde önemli olan faktörler vurgulandý. GEREÇ-YÖNTEM: Ocak 1984-Þubat 2007 tarihleri arasýnda kliniðimize yaygýn peritonit tablosu ile baþvurup, perfore apandisit ön tanýsý ile yatýrýlan ve ameliyat sýrasýnda SKP saptanan 5 çocuk (3 erkek, 2 kýz, ortalama yaþ 4,6) yakýnmalarý, klinik ve laboratuvar bulgularýyla cerrahi tedavi yöntemi açýsýndan geriye dönük olarak incelendi. BULGULAR: Olgular karýn aðrýsý, safralý kusma ve ateþ yakýnmasý ile baþvurdu; fiziksel incelemede karýnda yaygýn hassasiyet ve distansiyon vardý. Tüm olgularda lökositoz ve hafif hiperbilirubinemi, dördünde serum transaminaz yüksekliði, birinde kan þekeri yüksekliði, birinde konstipasyon saptandý. Olgularýn karýn ultrasonografisinde yaygýn serbest sývý görüldü; laparotomide öncelikli bulgu steril biliyer peritonitti. Eksplorasyonda SKP saptandý. Koledok T-tüp drenajý sonrasýnda hastanede ortalama 22 gün yatan olgularýn tümü þifa ile taburcu edildi. Beþ olgunun dördünde uzun pankreatobiliyer kanal varlýðý saptandý. SONUÇ: Uzun biliyopankreatik kanal SKP’de etyolojik faktör olarak düþünülmektedir. Çocukluk çaðýnda yaygýn peritonit, transaminaz yüksekliði ve hiperbilirubinemi ile baþvuran hastalarda SKP düþünülmelidir. Tedavide T-tüp drenajý öncelikle seçilmesi gereken yöntemse de bazý hastalarda Roux-en-Y hepatiko/portoenterostomi gereði doðabilir.

BACKGROUND: Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary maljunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. METHODS: Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. RESULTS: Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary maljunction was detected in 4 of 5 patients. CONCLUSION: In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

AMAÇ: Kot ve sternum kýrýklarý, eriþkinlerde kardiyopulmoner resüsitasyona (KPR) baðlý sýk rastlanan kas-iskelet sisteminin göðüs kafesi komplikasyonlarýndandýr. Çalýþmada kardiyak arest olgularýnýn tedavisinde uygulanan klasik kapalý göðüs basýsý nedeniyle oluþan kot ve sternum kýrýklarýnýn sýklýðýnýn saptanmasý amaçlandý.
GEREÇ-YÖNTEM: 2004-2005 yýllarýný içeren 12 aylýk süre içerisinde Pamukkale Üniversitesi Týp Fakültesi Adli Týp Anabilim Dalý tarafýndan otopsi uygulanan 231 olgu geriye dönük olarak incelendi. Yapýlan otopsilerden, KPR’ye baðlý kot-sternum kýrýklarý, ekimoz ve kostal bölge altý kanamayý içeren göðüs travmasý bulgusu olan 104 hasta çalýþmaya dahil edildi. BULGULAR: Yüz dört olgunun 91’i (%87,5) eriþkin, 13’ü (%12,5) çocuktu. Çocuk yaþ grubunda ortalama yaþ 5,48±5,96, kadýn/erkek oraný 5/8; eriþkin yaþ grubunda ortalama yaþ 44,88±18,31, kadýn/erkek oraný 18/73 olarak bulundu. Yapýlan 104 otopsinin 44’ünü (%42,3) travmatik nedenlerle, 60’ýný (%57,7) ise travma dýþý nedenlerle hayatýný kaybeden kiþiler oluþturmaktaydý. Eriþkin olgularýn otopsisinde ekimoz 26 (%28,8), kostal bölge altýnda kanama 16 (%17,6) ve göðüs kafesinde kýrýk (kot, sternum) ise 12 (%13,2) olguda bulundu. Eriþkin grupta KPR’ye baðlý göðüs travmasý açýsýndan yaþ, cinsiyet, travmatik-travma dýþý grup arasýnda istatistiksel fark bulunmadý (p>0,05). SONUÇ: Yapýlan otopsi sonuçlarýna göre kardiyak arrestin tedavisi olarak uygulanan kapalý göðüs masajýna baðlý kot ve sternum kýrýðý sýklýðý düþük bulunmuþtur.

BACKGROUND: Fractured ribs and sternum are frequent complications of thoracic compression during CPR (cardiopulmonary resuscitation) in adults. This study was conducted to determine the incidence of rib and sternal fractures after conventional closed-chest compression in the treatment of cardiac arrest. METHODS: We reviewed the forensic autopsy findings of 231 deaths referred to the Pamukkale University Department of Forensic Medicine over a 12-month period, 2004-2005. CPR-related chest injuries comprising rib and sternum fractures, ecchymosis and subcostal hemorrhage were compared retrospectively in 104 patients. RESULTS: Ninety-one (87.5%) of the 104 patients were adults, and 13 patients (12.5%) were children. The mean (SD) age in the pediatric group (5F/8M) was 5.48 (±5.96) and in the adult group (18F/73M) was 44.88 (±18.31). Forty-four (42.3%) of the 104 patients died of traumatic cause and 60 (57.7%) of non-traumatic cause. Ecchymosis was present in 26 (28.8%) patients, subcostal hemorrhage in 16 (17.6%) patients and fractures (sternal and costal) in 12 (13.2%) patients in adults. There were no significant differences between groups according to age, sex and traumatic-nontraumatic cause in terms of skeletal chest injuries associated with CPR in adult patients (p>0.05). CONCLUSION: This study shows a low incidence of rib and sternal fracture after closed-chest compression in the treatment of cardiac arrest in forensic autopsy cases.

AMAÇ: Travmatik diyafram yýrtýðý, göðüs cerrahisi ve genel cerrahi branþlarýný ilgilendiren, eþlik eden yaralanmalar nedeniyle acil ve hayati tehdit oluþturabilen bir durumdur. Bu çalýþmada, dokuz yýl içinde ameliyat edilen travmatik diyafram yaralanmalý olgulardaki sonuçlar deðerlendirildi. GEREÇ-YÖNTEM: Yüzüncü Yýl Üniversitesi Göðüs Cerrrahisi Anabililim Dalý’nda ameliyat edilen travmatik diyafram yýrtýklarý çalýþmaya alýndý. Taný direkt akciðer grafisi, bilgisayarlý toraks tomografisi, karýn ultrasonografisi ve gerektiðinde kontrastlý üst gastrointestinal inceleme ile konuldu. BULGULAR: Aðustos 1996-Ekim 2005 tarihleri arasýnda Yüzüncü Yýl Üniversitesi Týp Fakültesi Göðüs Cerrahisi Anabilim Dalý’nda 26 travmatik diyafram yaralanmalý olgu (21 erkek, 5 kadýn; ort. yaþ 33; daðýlým 13-67) ameliyat edildi. On beþ olguda torakotomi, yedi olguda laparotomi, dört olguda ise torakotomi + laparotomi yapýldý ve hepsinde diyaframa primer tamir uygulandý. On sekiz olguda sol, sekiz olguda sað diyaframda yýrtýk saptandý. Diyaframdaki laserasyon 0,5-15 cm arasýnda deðiþiyordu. Biri dýþýnda diðer olgularda, çeþitli eþlik eden yaralanmalar da vardý; 12 olguda karýn organlarý toraksa herniye idi. Acil olarak ameliyata alýnan ve ciddi yaralanmalarýn eþlik ettiði üç olgu ameliyat sýrasýnda hayatýný kaybetti. Ameliyat sonrasý dönemde mortalite olmadý, morbidite beþ olguda meydana geldi. SONUÇ: Travmatik diyafram yýrtýðý gözden kaçýrýldýðýnda ve eþlik eden ciddi yaralanmalar olduðunda komplikasyonlara ve hatta ölüme bile neden olabilir. Taný ve tedavisi hýzlý ve dikkatli bir þekilde ele alýnmalýdýr.

BACKGROUND: Traumatic diaphragmatic rupture is an urgent and life-threatening condition concerning the branches of chest surgery and general surgery because of the accompanying injuries. We reviewed the results of our cases with traumatic diaphragmatic rupture who were operated over a period of 9 years. METHODS: The patients who underwent surgery for traumatic diaphragmatic rupture in Department of Chest Surgery Medicine Faculty of Yuzuncu Yýl University were included into the study. The diagnosis was established by chest X-ray, computerized thoracic tomography, abdominal ultrasonography, and contrast upper gastrointestinal imaging modalities when needed. RESULTS: Twenty-six cases (21 males, 5 females; mean age 33; range 13 to 67 years) with traumatic diaphragmatic rupture were operated in Department of Chest Surgery Medicine Faculty of Yuzuncu Yýl University between August 1996 and October 2005. Treatment approach in 15 cases was thoracotomy, in 7 cases laparotomy and in 4 cases thoracotomy + laparotomy, and in all cases, diaphragma was primarily sutured. Left diaphragmatic rupture was detected in 18 cases and right diaphragmatic rupture in 8 cases. Laceration in the diaphragma ranged between 0.5 and 15 cm. Various accompanying injuries were present in all cases except one. Abdominal organs were herniated to the thorax in 12 cases. Three cases who were operated on urgently with severe accompanying injuries died. There was no mortality in the postoperative period and morbidity occurred in 5 cases. CONCLUSION: Traumatic diaphragmatic rupture, when overlooked and accompanied with severe injuries, can cause complications and even death. Its diagnosis and treatment must be dealt with rapidly and cautiously.

AMAÇ: Genç hastalarda femur boyun kýrýklarý kesin redüksiyon ve stabil tespiti gerektiren acil yaralanmalardýr. Tüm geliþmelere raðmen femur baþý avasküler nekrozu (AVN) ve kaynamama kurtarýcý ameliyatlar gerektiren en önemli komplikasyonlardýr. Bu geriye dönük çalýþmada, internal tespit yapýlan femur boyun kýrýklarýnýn komplikasyonlarý deðerlendirildi. GEREÇ-YÖNTEM: Deplase femur kýrýklý 32 hasta çalýþmaya dahil edildi. Bazý hastalar ilk yaralanmadan sekiz saat sonra hastanemize baþvurmalarýna raðmen en erken zamanda ameliyata alýndýlar. Açýk redüksiyon gerektiren beþ hasta dýþýnda tüm olgulara kapalý redüksiyon ve tespit uygulandý. AVN, Ficat ve Arlet kriterlerine göre deðerlendirildi. Klinik deðerlendirme Harris tarafýndan tanýmlanan puanlama sistemine göre yapýldý. BULGULAR: Ortalama izlem süresi 49±29 aydý (daðýlým 24-126). On üç olguda femur baþý avasküler nekrozu belirlendi (%40); ancak yalnýzca beþ olguda yetersiz sonuca baðlý total kalça protezi uygulandý. Beþ olguda da kaynamama saptandý. Yapýlan istatistiksel analizde, AVN derecesi ve klinik puanlar arasýnda ters iliþki belirlendi. Ameliyata alýnma süresi ile geç komplikasyonlar arasýnda iliþki saptanmadý.
SONUÇ: Deplase femur boyun kýrýklarýnýn en sýk komplikasyonu AVN’dir. Ancak olgularýn yarýdan azýna kurtarýcý ameliyat gerekmiþtir. Bu olgularda total kalça protezi uygun tedavi seçeneðidir.

BACKGROUND: Femoral neck fractures in young patients are the emergent injuries that require precise reduction and stable fixation. Despite all advances, nonunion and avascular necrosis (AVN) of the femoral head are the major complications necessitating salvage procedures. In this retrospective series, we evaluated the complications of internally fixed femoral neck fractures. METHODS: This study consisted of 32 cases that had displaced femoral neck fractures. Although some of them admitted to hospital more than 8 hours after initial trauma, all underwent internal fixation as early as possible. All the fractures were reduced and fixed by closed reduction under fluoroscopy control. However, 5 cases needed open reduction. AVN was determined by using Ficat and Arlet criteria. Clinical evaluation was performed based on the scoring system described by Harris. RESULTS: Mean follow-up period was 49±29 months (range 24-126). AVN of the femoral head was observed in 13 cases (40%). However, only 5 of them had unsatisfactory clinical results requiring salvage surgery as total hip replacement. Nonunion of fracture was seen in 5 cases. In the statistical analysis, a negative correlation was observed between the degree of AVN and clinical findings. We found no correlation between the duration of the preoperative period and late complications.
CONCLUSION: AVN is the most common complication of displaced femoral neck fractures. However, less than half of these cases require salvage procedures. Total hip replacement is the preferred treatment option for these cases.

AMAÇ: Torakoabdominal yaralanmalarda morbidite ve mortaliteyi etkileyen prognostik faktörler deðerlendirildi. GEREÇ-YÖNTEM: Haziran 1996-Kasým 2005 tarihleri arasýnda torakoabdominal yaralanmaya maruz kalan ve laparotomi uygulanan 250 hasta (227 erkek, 23 kadýn; ort. yaþ 30,1±5,11; daðýlým 15-71) geriye dönük olarak incelendi. Hastalar yaþ, cinsiyet, travma operasyon entervali, þok, yatýþ süresi, yaralanan organ sayýsý, kan transfüzyonu, kapalý toraks drenajý, torakotomi, abdominal travma indeksi, yaralanma þiddet skoru, kýsaltýlmýþ yaralanma ölçeði, revize edilmiþ travma skoru ve komplikasyonlara göre deðerlendirildi. BULGULAR: Genel mortalite oraný %15,6, morbidite oraný ise %53,5 idi. Mortaliteye etkili faktörler, travma operasyon entervali ≥3 saat (p=0,03), þok mevcudiyeti (p=0,003), kan transfüzyon sayýsýnýn artmasý (p=0,001), yaralanan organ sayýsýnýn ≥3 olmasý (p=0,001) ve erken dönem kapalý toraks drenajý yapýlmamasý (p=0,008) idi. Travma operasyon entervali <3 saat (p=0,02), kan transfüzyon sayýsýnýn artmasý (p=0,02), yaralanan organ sayýsýnýn ≥3 olmasý (p=0,001) ve erken dönem kapalý toraks drenajý yapýlmamasý (p=0,005) morbiditeye etkili faktörlerdi. SONUÇ: Travma operasyon entervalinin üç saatten fazla olmasý, yaralanan yandaþ organ sayýsýnýn üçten fazla olmasý ve kan transfüzyon sayýsýnýn artmasýnýn mortalite ve morbiditeyi artýrdýðý saptandý, fakat þok mevcudiyetinin sadece mortaliteyi artýrdýðý gözlendi. Diðer tarafdan kapalý toraks drenajýnýn uygun zamanda uygulanmasýnýn mortalite ve morbiditeyi azalttýðý saptandý.

BACKGROUND: Prognostic factors affecting mortality and morbidity in thoracoabdominal injuries were evaluated. METHODS: Two hundred and fifty patients (227 males, 23 females; mean age 30.1±5.11; range 15 to 71 years) who had been exposed to thoracoabdominal injuries and underwent laparotomy between June 1996 and November 2005 were investigated retrospectively. Patients were assessed according to age, sex, trauma-operation interval, shock, hospitalization period, number of injured organs, blood transfusion, timing of closed thorax drainage, thoracotomy, Abdominal Trauma Index, Injury Severity Score, Abbreviated Injury Score, Revised Trauma Score, and complications. RESULTS: Mortality and morbidity ratios were 15.6% and 53.5%, respectively. The factors effective on mortality were trauma-operation interval ≥3 hours (p=0.03), presence of shock (p=0.03), increase in the rate of blood transfusion (p=0.001), injured organ number ≥3 (p=0.001), and not performing early-term closed thorax drainage (p=0.005). Trauma-operation interval <3 (p=0.02), increase in the rate of blood transfusion (p=0.02), injured organ number ≥3 (p=0.001), and not performing early-term closed thorax drainage (p=0.005) were the factors effective on morbidity.
CONCLUSION: It was determined that trauma-operation period ≥3 hours, number of injured organs ≥3, and increased number of blood transfusions increased both mortality and morbidity. However, presence of shock increased only mortality. On the other hand, application of closed thorax drainage within a reasonable time period was determined to decrease mortality and morbidity.

AMAÇ: Bu çalýþmada, Samsun’da hastane acil servisleri ve 112 acil çalýþanlarýnýn son 12 ay içinde þiddete maruziyeti ve durumluk-sürekli kaygý düzeylerinin deðerlendirilmesi amaçlandý. GEREÇ-YÖNTEM: 1-30 Nisan 2004 tarihleri arasýnda, Samsun il merkezindeki beþ acil yardým istasyonu ve dört hastane acillerinin tümünde, kesitsel tipte bir araþtýrma planlandý. Anket formunu katýlýmcýlarýn tamamýnýn (n=320) kendi kendilerine doldurmalarý istendi. BULGULAR: Katýlýmcýlarýn 280’i (%87,5) araþtýrmaya katýldý. Araþtýrmaya katýlanlarýn toplam 202’si (%72,1) herhangi bir formdaki þiddete maruz kaldýðýný bildirdi. Hastane acil servis çalýþanlarýnýn (%75,9), 112 acil çalýþanlarýna (%62,3) göre daha fazla þiddete maruz kaldýðý bulundu (c2=5,08, p<0,05). Çok deðiþkenli analiz sonuçlarýna göre yaþ, cinsiyet ve tekrar þiddete maruz kalma kaygýsýnýn yüksek durumluk kaygý puaný ile, tekrar þiddete maruz kalma kaygýsýnýn yüksek sürekli kaygý puaný ile iliþkili olduðu saptandý. SONUÇ: Bu sonuçlar hastane acilleri ve 112 acillerinde, þiddetin yaygýn olduðunu açýkca göstermektedir. Ýþyerindeki þiddetin azaltýlmasý ve yok edilmesi için gerekli çalýþmalar yapýlmalýdýr.

BACKGROUND: The aim of this study was to determine the frequency of exposure to some form of violence during the previous 12 months and the State-Trait Anxiety levels of emergency medical care (EMC) and emergency service (ES) workers in Samsun.
METHODS: A cross-sectional study was conducted in all EMC (5) units and ES (4) in Samsun, between April 1 and April 30, 2004. A self-administered questionnaire was sent to all of the workers (n=320). RESULTS: Of the workers, 280 (87.5%) completed the survey. A total of 202 (72.1%) participants reported that they had witnessed some form of violence. ES workers (75.9%) were more often exposed to violence than EMC workers (62.3%) (c2=5.08, p<0.05). The multivariate analysis demonstrated that age, gender and anxiety regarding repetition of exposure to violence were related with higher state anxiety point, while anxiety regarding repetition of exposure to violence was related with higher trait anxiety point. CONCLUSION: This evidence clearly indicates that violence in ES and EMC units is a common concern. The necessary framework for the reduction and elimination of violence in the workplace should be provided.

Umbilikal fýtýk, çocuklarda karýn ön duvarýnýn sýk karþýlaþýlan doðumsal patolojilerinden biridir. Çocuklarda görülen umbilikal herni, yüksek sýklýkla kendiliðinden kapanma eðilimindedir. Cerrahi tedavi ancak seyrek görülen komplikasyonlar geliþtiðinde gereklidir. Umbilikal fýtýk kesesi içerisinde geliþen bir apandisit olgusu, daha önce bildirilmemiþtir. Bu olgu, Ýngilizce literatürde bir ilktir.

Umbilical hernia is one of the most common congenital pathologies of the anterior abdominal wall in children. Umbilical hernia in children has a high tendency for spontaneous closure. Surgical treatment is performed only for rarely occurring complications. Appendicitis within an umbilical hernia sac is a previously unreported complication for umbilical hernias. We report here the first case in the current English language literature.

Bu yazýda, orbita tavan kýrýðýna baðlý bir akut travmatik orbital ensefalosel olgusunun taný ve tedavisi sunuldu. Orbita tavan kýrýðýna baðlý akut travmatik ensefalosele nadiren rastlanýr. Artmýþ intraorbital basýnç, optik sinirde geri dönüþümsüz hasara neden olabileceði için bu olgularda erken taný ve tedavi çok önemlidir. Ýnce kesitli aksiyel ve koronal orbita bilgisayarlý tomografi incelemesi, orbita travmasýnýn eþlik ettiði tüm akut travmalý hastalara uygulanmalýdýr. Bu olgularýn cerrahi tedavisinde orbita tavan kýrýðýnýn tamiri en önemli basamaktýr ve mutlaka yapýlmalýdýr. Porlu polietilen (Medpor®) birçok açýdan diðer allogreftlere üstünlüðü olan ve uzun yýllardýr rekonstrüksiyon ameliyatlarýnda kullanýlan bir materyaldir. Sunulan olguda orbita tavan rekonstrüksiyonu Medpor® kullanýlarak yapýldý, erken ve geç dönemde mükemmel sonuçlar elde edildi. Orbita tavan kýrýðý sonrasý geliþen akut travmatik ensefaloselin baþvuru tablosu, taný ve cerrahi basamaklarý hakkýndaki önemli noktalar vurgulandý.

A case report of acute traumatic orbital encephalocele related to orbital roof fracture and its management were presented. Acute traumatic encephalocele related to orbital roof fracture is unusual. Early diagnosis and treatment are very important since the raised intraorbital pressure may irreversibly damage the optic nerve. Orbital computerized tomography with thin axial and coronal sections should be performed in an acute traumatized patient with a concurrent orbital trauma. Reconstruction of the orbital roof is the key step of the surgical treatment and should be performed in every case. Porous polyethylene (Medpor®) has been used for many years in reconstructive surgeries and it is superior to other allografts in many ways. In our case, the orbital roof reconstruction was done by Medpor® and the early and late cosmetic results were excellent. The important features of acute traumatic encephalocele secondary to orbital roof fractures in terms of presentation, diagnosis and surgical steps were also stressed.

Künt karýn travmalarý sonrasýnda travmatik lomber fýtýk nadir olarak görülür. Bu olgularda karýniçi organ yaralanmasý sýktýr. Travmatik lomber fýtýk olgularýnda fiziksel inceleme taný için önemli olmakla birlikte, bilgisayarlý tomografi tanýyý doðrulamada, eþlik eden karýniçi organ yaralanmasý olup olmadýðýný anlamada ve tedavi yöntemini seçmede faydalýdýr. Eþlik eden strangülasyon ve/veya karýniçi yaralanma þüphesi varsa acil laparotomi veya laparoskopi yapýlmalýdýr, fakat böyle bir þüphe yoksa ekstraperitoneal olarak primer ya da prostetik materyal ile güvenli bir þekilde onarýlabilir. Bu yazýda, künt karýn travmasý nedeniyle oluþan izole, akut lomber fýtýk olgusunun laparotomisiz polipropilen protezle tamiri tartýþýldý.

Traumatic lumbar hernia is a rare consequence of blunt abdominal injury. In these cases, intraabdominal visceral injuries are common. Although physical examination is important for this diagnosis, computed tomography is valuable for confirming the diagnosis, eliminating associated intraabdominal injuries and deciding the treatment modality of traumatic lumbar hernia. If there is a suspicion of associated strangulation and/or intraabdominal injury, emergent laparotomy or laparoscopy must be performed. If there is no suspicion of these, extraperitoneal repair primarily or with prosthetic material can be performed safely. We present a case of an isolated acute lumbar hernia due to blunt abdominal trauma, and we discuss mesh repair without laparotomy as the treatment modality.

Bu yazýda, kronik böbrek yetersizliði nedeniyle hemodiyaliz uygulanan bir olgunun, akut karýn aðrýsýyla baþvurmasý sonrasý taný konan non-oklüzif mezenterik iskemi (NOMÝ) sunuldu. Olgunun karýn bilgisayarlý tomografi (BT) ve BT anjiyografi incelemesinde, süperior ve inferior mezenterik arter açýk olarak izlendi; beraberinde mezenterik venlerde gaz ve pnömotozis intestinalis varlýðý saptandý. BT incelemesinde, ayný zamanda terminal ileum düzeyinde duvar kalýnlaþmasý ve yað dokusunda dansite artýþlarý saptandý. Acil laparotomide terminal ileum düzeyinde 4 cm’lik bir segmentte nekroz varlýðý belirlendi, iskemik segment rezeke edildi. Histopatolojik inceleme gangrenöz enterit ile uyumluydu. Bu NOMÝ olgusunda, konu ile iliþkili literatür gözden geçirildi, görüntüleme bulgularý sunuldu.

We report non-occlusive mesenteric ischemia (NOMI) in a patient with hemodialysis-dependent chronic renal failure who presented with acute onset of abdominal pain. On abdominal computed tomography (CT) and CT angiography, pneumatosis intestinalis of the small intestine and mesenteric venous gas were found with patent superior and inferior mesenteric arteries. CT also showed bowel wall thickening with fat stranding at terminal ileum. In emergency laparotomy, necrosis of the terminal ileum over a 4 cm area was identified and the ischemic segment was resected. Histopathological exam was consistent with gangrenous enteritis. Herein, we present exquisite imaging findings of a NOMI case with an overview of related literature.