Management of liver injury is challenging particularly for the advanced grades. Increased utility of nonoperative management strategies increases the risk of developing massive liver necrosis (MLN). We reported a case of a 19-year-old male who presented with a history of motor vehicle crash. Abdominal computerized tomography (CT) scan revealed large liver laceration (Grade 4) with blush and moderate free hemoperitoneum in 3 quadrants. Patient was managed nonoperatively by angioembolization. Two anomalies in hepatic arteries origin were reported and both vessels were selectively cannulated and bilateral gel foam embolization was achieved successfully. The patient developed MLN which was successfully treated conservatively. The follow-up CT showed progressive resolution of necrotic areas with fluid replacement and showed remarkable regeneration of liver tissues. We assume that patients with high-grade liver injuries could be managed successfully with a carefully designed protocol. Special attention should be given to the potential major associated complications. A tailored multidisciplinary approach to manage the subsequent complications would represent the best recommended strategy for favorable outcomes.

Pneumomediastinum (PM) is mainly an atypical finding among traumatic neck or thoracic injury patients. Moreover, PM secondary to isolated orbital floor fracture remains a rare event which is infrequently associated with severe complications such as mediastinitis, airway obstruction and pneumothorax. Herein, we report an atypical case of mediastinal emphysema consequent to orbital floor fracture along with review of the literature.

Background Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. Methods A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). Results A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062–16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157–1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. Conclusion The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. Trial registration ClinicalTrials.gov Identifier: NCT03846973.

INTRODUCTIONBlunt esophageal injury is extremely rare event. However, it is a potential morbid injury unless managed early.PRESENTATION OF CASEWe report a rare case of blunt esophageal injury for a 28-year old male who presented with history of fall of heavy object over the right side of the chest. Diagnostic work up including chest X-ray, computerized tomography scans and gastrografin esophagogram revealed lower esophageal rupture. Right mini-thoracotomy with esophageal repair was performed. Postoperative course was uneventful.DISCUSSIONThe exact mechanism of blunt esophageal injury remains uncertain. This report described a unique location of esophageal rupture after blunt trauma that happened on the right side. Diagnosis of esophageal injury needs high index of suspicion and accurate diagnostic workup.CONCLUSIONPrompt diagnosis and management are the key for better prognosis in patients with blunt esophageal injury.

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