Video-assisted thoracoscopic surgery for acute thoracic trauma

Background:

Operative intervention for thoracic trauma typically requires thoracotomy. We hypothesized that thoracoscopy may be safely and effectively utilized for the acute management of thoracic injuries.

Materials and Methods:

The Trauma Registry of a Level I trauma center was queried from 1999 through 2010 for all video-assisted thoracic procedures within 24 h of admission. Data collected included initial vital signs, operative indication, intraoperative course, and postoperative outcome.

Results:

Twenty-three patients met inclusion criteria: 3 (13%) following blunt injury and 20 (87%) after penetrating trauma. Indications for urgent thoracoscopy included diaphragmatic/esophageal injury, retained hemothorax, ongoing hemorrhage, and open/persistent pneumothorax. No conversions to thoracotomy were required and no patient required re-operation. Mean postoperative chest tube duration was 2.9 days and mean length of stay was 5.6 days.

Conclusion:

Video-assisted thoracoscopic surgery is safe and effective for managing thoracic trauma in hemodynamically stable patients within the first 24 h post-injury.

Management of thoracic trauma in emergency service: Analysis of 1139 cases

OBJECTIVE

Thoracic trauma is a common cause of significant morbidity and mortality. This study presents a series of thoracic trauma with the aim to assess epidemiologic features, distribution of pathologies, additional systemic injuries, diagnosis, management and outcome.

METHODOLOGY

Between January 2007 and December 2011, all patients with thorax trauma admitted to the emergency service of our hospital were retrospectively reviewed with respect to age, gender, etiological factors, distribution of pathologies, additional systemic injuries, diagnosis, treatment modalities, referral and outcome.

RESULTS

A total of 1139 patients with thorax trauma were included in the study. Of these, 698 (61.3%) were male and 441 (38.7%) were female, and the average age was 54.17±17.39 years. 1090 (95.7%) of the patients had blunt trauma, whereas 49 (4.3%) had penetrating trauma. Etiological factors were falls in 792 (69.5%), motor vehicle accidents in 259 (22.8%), animal related accidents in 39 (3.4%) and penetrating injuries in 49 (4.2%) patients. It was found that 229 (20%) patients had single, 101 (8.9%) had double, 5 (3%) had three or more, 10 (0.9%) had bilateral rib fractures and 19 (1.7%) had sternal fracture. Pneumothorax was diagnosed in 58 (5.1%) patients, whereas hemothorax, hemopneuomothorax and other system injuries were diagnosed in 36 (3.2%), 38(3.3%) and 292 (25.6%) respectively. In our series, thirteen patients (mortality rate 1.1%) died as result of hemorrhagic shock (n=8), respiratory distress (n=3) and severe multiple trauma (n=2).

CONCLUSION

Although majority of the patients with thorax trauma receive treatment as outpatients; thoracic traumas may be a life threatening condition, and should be identified and treated immediately. Mortality varies based on etiological factors, additional systemic pathologies, capabilities of the hospital especially diagnostic and treatment facilities in emergency services. We believe that a multidisciplinary approach to the patients with severe thorax trauma, and the opportunities of emergency bedside thoracotomy in emergency services will significantly reduce the morbidity and mortality.

Chronic pain and its impact on quality of life following a traumatic rib fracture

PURPOSE

Traumatic rib fractures account for 7-40 % of trauma admissions and most of them heal spontaneously and do not contribute to disability. The prevalence of chronic pain and its impact on quality of life following a traumatic rib fracture has not been studied adequately.

METHODS

A retrospective review of electronic medical records of all the traumatic rib fracture admissions from January 2007 to December 2008 was conducted. This was followed up with a brief telephonic survey of the following questions: (1) Do you have pain following the trauma? (2) If YES, how severe is your pain from a score of zero to ten? (3) Does the pain affect your life style? (4) Does the pain affect your work? (5) Do you need to take regular pain medications?

RESULTS

One hundred and two patients responded to the survey and 23 patients (22.5 %) complained of chronic persistent pain. In patients with pain, six patients (26 %) had chronic pain that required regular use of analgesics, eight patients (35 %) complained of impairment of work life, and three patients (13 %) complained of impairment of personal quality of life. Chronic pain was not related to age, number of ribs fractured, flail chest, hemothorax and/or pneumothorax, chest tube insertion, or Injury Severity Score (ISS).

CONCLUSION

This study confirms the high incidence of chronic pain after a traumatic rib fracture. While the majority of the patients can manage this pain without interference of their quality of life, a few do suffer from life style/work interference and may have to resort to regular analgesic usage.

Digital radiography of crush thoracic trauma in the Sichuan earthquake

AIM: To investigate the features of crush thoracic trauma in Sichuan earthquake victims using chest digital radiography (CDR).

METHODS: We retrospectively reviewed 772 CDR of 417 females and 355 males who had suffered crush thoracic trauma in the Sichuan earthquake. Patient age ranged from 0.5 to 103 years. CDR was performed between May 12, 2008 and June 7, 2008. We looked for injury to the thoracic cage, pulmonary parenchyma and the pleura.

RESULTS: Antero-posterior (AP) and lateral CDR were obtained in 349 patients, the remaining 423 patients underwent only AP CDR. Thoracic cage fractures, pulmonary contusion and pleural injuries were noted in 331 (42.9%; 95% CI: 39.4%-46.4%), 67 and 135 patients, respectively. Of the 256 patients with rib fractures, the mean number of fractured ribs per patient was 3. Rib fractures were mostly distributed from the 3rd through to the 8th ribs and the vast majority involved posterior and lateral locations along the rib. Rib fractures had a significant positive association with non-rib thoracic fractures, pulmonary contusion and pleural injuries (P < 0.001). The number of rib fractures and pulmonary contusions were significant factors associated with patient death.

CONCLUSION: Earthquake-related crush thoracic trauma has the potential for multiple fractures. The high number of fractured ribs and pulmonary contusions were significant factors which needed appropriate medical treatment.

Telesurgical evaluation of stable thoracic trauma patients: a feasibility study

BACKGROUND

We evaluated a robotic telesurgical platform in managing thoracic trauma in an animal model.

STUDY DESIGN

The da Vinci(®) robot was used to evaluate and treat a random number of blinded injuries in ten porcine thoraces.

RESULTS

Ninety-five percent of injuries were correctly identified. The median survey time was 20.5 min (range 16-63 min). The mean time to repair lung lacerations was 19.8 min (range 14-27.5 min) and to evacuate the hemothoraces, it was 5.3 min (range 4.5-6.5 min). Diaphragmatic lacerations required repositioning of the ports and the robot. Only two out of five lacerations were successfully repaired (mean time 38.8 min, range 32.5-45 min). All aortic injuries were correctly identified. One subject died of a pre-existing pneumonia.

CONCLUSIONS

A robotic telesurgical approach to the evaluation of stable thoracic trauma patients is safe and feasible in a porcine model. Diaphragmatic injuries can be repaired but require repositioning of the robot.

Thoracotomy in Thoracic Injuries: Results from a Tertiary Referral Hospital

INTRODUCTION

Critically injured patients may require thoracotomy after a thoracic injury. This study is a retrospective analysis of the results of thoracotomy in patients with thoracic injury.

MATERIALS AND METHODS

Injured patients with detectable signs of life on arrival at the hospital and who underwent thoracotomy within 4 h of the injury were investigated. Demographic data and medical records were reviewed for associated injuries, indications, intraoperative findings, and outcomes. The factors affecting the mortality were analyzed.

RESULTS

Between April 2003 and January 2009, 488 patients with thoracic injury (blunt/penetrating = 73.7%/26.3%) were treated, and 20 (4.1%) underwent thoracotomy (male/female = 17/3, mean age = 27 ± 9 years). The injury was penetrating in 15 (11.7%) and blunt in five (1.4%). None of them required an endotracheal intubation at the scene or in transit. The mean transport time was 58 min. Severe and continuous hemothorax (80%), massive air leak, major vessel injury, and trauma causing an open chest wall defect with bleeding were indications of the thoracotomy. Eighty-five percent survived after the surgery (penetrating/ blunt = 86.6%/80%). The mean injury severity score (ISS) of the survivors was lower (21 ± 9 vs. 39 ± 10, p = 0.05). Mortality was associated with a lower Glasgow coma scale (GCS) (p = 0.03), a higher ISS (p = 0.05), and a longer transport time (p = 0.05).

CONCLUSIONS

Thoracotomy after thoracic injury is a life-saving procedure in selected cases. Lower GCS and higher ISS are associated with increased mortality. Early transport and quick attempts to diagnose the indications necessitating thoracotomy play a significant role in improving the outcome.

Mortality in patients with loss of consciousness at the scene of trauma

BACKGROUND AND AIM

The aim of this study was to evaluate if loss of consciousness at the scene of an accident in patients with thoracic trauma classified by the Abbreviated Injury Scale (AIS) as thorax >2 has a different outcome in respect to immediate hospital discharge, hospitalization, death and type of accident.

METHODS

A prospective study was performed in the Regional Trauma Center of São José do Rio Preto. All patients with scores related to thoracic injury >/=2 were included in this study. Thus, 134 patients with penetrating and 231 with blunt thoracic injuries were evaluated. The chi-square, Fisher's exact and relative risk tests were utilized for statistical analysis with an alpha error greater than 5% (p < 0.05) being considered statistically significant.

RESULTS

A significantly higher number of patients who lost consciousness (35-33.9%) died compared to those who did not lose consciousness (9-3.5%, Fisher's exact test: p < 0.0001) where the relative risk (RR) of death when an individual lost consciousness was 9.7 (95% CI: 4.8-19.4). In respect to the necessity of hospital treatment, those who lost consciousness were more commonly hospitalized (Fisher's exact test: p < 0.0001).

CONCLUSION

The loss of consciousness at the time of trauma is a warning sign in patients with thoracic injuries whether associated with other types of injuries or not.

The Epidemiology of Traumatic Hemothorax in a Level I Trauma Center: Case for Early Video-assisted Thoracoscopic Surgery

OBJECTIVE

Hemothorax is a common sequela of chest trauma. Complications after chest trauma include retained hemothorax and empyema requiring multiple interventions. We studied the epidemiology of hemothorax and its complications at a level I trauma center.

METHODS

The trauma registry was reviewed from Jan 1995 toMay 2005.Allpatients ≥16 years of agewhowere admitted with hemothorax, an AIS chest score of ≥ 3, and did not receive an immediate thoracotomy were entered in the study cohort. The patient demographics, details of the injury event, treatments, hospital length of stay (LOS), complications and outcome were analyzed.

RESULTS

The study cohort of 522 patients with a hemothorax were treated with 685 chest thoracostomy tubes. Overall, the median ISS was 18 and 62% were penetrating injuries. 109 patients (21%) had a retained hemothorax and required placement of ≥ 2 chest tubes with a median LOS of 15 days longer than patients with no retained hemothorax (p < 0.0001). The overall complication rate was 5% (26/522). Of these, 20 patients had empyema (3.8%), 8 patients required decortication, and 6 patients received streptokinase treatment.

CONCLUSION

More than 1 out of every 5 patients undergoing intervention for trauma-induced hemothorax develops a complication. The development of retained hemothorax is associated with empyema in 15.6% of cases and a 2-week median increase in length of stay. Future research into interventions such as Video-assisted thoracoscopic surgery (VATS) on the day of admission to completely evacuate hemothorax is warranted to reduce complication rates, length of stay and cost.