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BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

<h4>Introduction</h4>Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy.<h4>Presentation of case</h4>A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures.<h4>Discussion</h4>Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest.<h4>Conclusion</h4>When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

Background: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). Methods: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). Results: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50–4.16 and AOR: 4.98; 95 % CI, 2.75–9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. Conclusion: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. Level of Evidence: Level 4; Therapeutic/Care management.

BACKGROUND: The management of cardiac trauma requires rapid intervention in the emergency room, facilitated by a surgeon with prior experience to have good outcomes. Many surgeons have little experience in the requisite procedures. We report here 4 patients who suffered cardiac trauma, and all 4 patients survived with good neurologic outcomes. CASE PRESENTATIONS: Patient 1 suffered blunt cardiac trauma from a motor vehicle accident and presented in shock. Cardiac tamponade was diagnosed and a cardiac rupture repaired with staples through a median sternotomy after rapid transport to the operating room. Patient 2 suffered blunt cardiac trauma and presented in shock with cardiac tamponade. Operating room median sternotomy allowed extraction of pericardial clot with recovery of physiologic stability. Patient 3 presented with self-inflicted stab wounds to the chest and was unstable. She was brought to the operating room and thoracotomy allowed identification of a left ventricle wound which was repaired with a suture. Patient 4 presented in cardiac arrest with multiple self-inflicted stab wounds to the chest. Emergency room thoracotomy allowed repair of a right ventricle laceration with recovery of vital signs. CONCLUSIONS: The management of all 4 patients was according to the principles taught in the ATOM course. Three of the 4 surgeons had no prior experience with management of cardiac trauma and credited the good outcomes to taking the ATOM course. These are uncommon injuries and formal training in their management is beneficial to patients.

A 75-year-old pedestrian was struck by a truck and in shock with both lower extremities significantly deformed, with injuries extending proximally to the inguinal region and degloving injuries. Resuscitative endovascular balloon occlusion of the aorta was performed to achieve temporary hemostasis and the patient became hemodynamically stable. Following stabilization, both lower extremities were amputated. Resuscitative endovascular balloon occlusion of the aorta may be effective to achieve temporary hemostasis in patients with extensive injuries of the lower extremities, especially with extension to the inguinal region which precludes use of a tourniquet.