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O'Connor J, Adamski J. The Diagnosis and Treatment of Non-Cardiac Thoracic Trauma. J ROY ARMY MED CORPS 2010; 156:5-14. [DOI: 10.1136/jramc-156-01-02] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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The Clinical Outcome of Occult Pulmonary Contusion on Multidetector-Row Computed Tomography in Blunt Trauma Patients. ACTA ACUST UNITED AC 2010; 68:387-94. [DOI: 10.1097/ta.0b013e3181a7bdbd] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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103
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Rezende-Neto JB, Hoffmann J, Al Mahroos M, Tien H, Hsee LC, Spencer Netto F, Speers V, Rizoli SB. Occult pneumomediastinum in blunt chest trauma: clinical significance. Injury 2010; 41:40-3. [PMID: 19604507 DOI: 10.1016/j.injury.2009.06.161] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/16/2009] [Accepted: 06/16/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or "overt pneumomediastinum", raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or "occult pneumomediastinum". Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population. METHODS A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated. RESULTS Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p<0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p<0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam. CONCLUSION Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.
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Affiliation(s)
- J B Rezende-Neto
- Tory Regional Trauma Centre & Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
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Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management. ACTA ACUST UNITED AC 2009; 67:1080-6. [PMID: 19901671 DOI: 10.1097/ta.0b013e318189371d] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients. PATIENTS For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT. RESULTS The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87). CONCLUSION All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.
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Abstract
OBJECTIVE To investigate, in children, the correlation between the extent of lung contusion as detected on early radiologic examination (chest radiograph [CXR] and/or thoracic computed tomography [TCT]) and subsequent clinical outcome measures. DESIGN Retrospective chart review study with blinded assessment of thoracic imaging. SETTING A university-affiliated, level 1 designated pediatric trauma center. INTERVENTIONS None. PATIENTS Patients (1-18 yrs) who, between April 2000 and October 2005, were diagnosed with lung contusion were eligible for study entry. The medical records of those patients who underwent early (within the first 24 hrs of admission) thoracic imaging (CXR and/or TCT) were reviewed. A pulmonary contusion score (PCS) was assigned to each thoracic image according to the extent of contusion injury by two investigators blinded to each others score and the clinical details of the patient. RESULTS Seventy-four patients were included in the study. Twenty patients had undergone CXR only, whereas 54 had undergone both CXR and TCT. The mean PCS on CXR was 3.9 +/- 3.6 compared with 6.5 +/- 3.49 on TCT (p < .001). In eight patients (15%) who underwent TCT and CXR, the CXR failed to demonstrate a lung contusion. The PCS derived from CXR examination correlated positively with lower Pao2/Fio2 (r = -.36, p = .019), higher ventilation index (r = .35, p = .014), and longer length of ventilation (r = .28, p = .019). No such correlation was seen with TCT-derived PCS. CONCLUSIONS The severity of lung contusion determined by CXR, but not TCT, correlates with impairment of oxygenation, CO2 exchange, and duration of ventilatory support.
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Molena D, Burr N, Zucchiatti A, Lovria E, Gestring ML, Cheng JD, Bankey PE, Stassen NA. The Incidence and Clinical Significance of Pneumomediastinum Found on Computed Tomography Scan in Blunt Trauma Patients. Am Surg 2009. [DOI: 10.1177/000313480907501111] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the increased use of chest computed tomography (CT) scan in the initial evaluation of major trauma, findings that were not seen on a chest radiograph (CXR) are increasingly identified. Pneumomediastinum (PM) seen on CXR in blunt trauma patients is considered worrisome for airway and/or esophageal injury. The purpose of this study was to determine the incidence and clinical significance of PM found on CT in blunt trauma patients. Blunt trauma patients admitted to a single Regional Trauma Center over a 2-year period were identified. Records were reviewed for demographics, mechanism, diagnostic evaluations, injuries, and outcome. A total of 2052 patients met study criteria. Fifty-five (2.7%) had PM; 49 patients (89%) had PM identified on CT alone, whereas six patients (11%) had it identified on both CXR and CT. There was no significant difference in gender or age between the two groups. Associated injuries were similar between groups. No patients had tracheobronchial or esophageal injuries. In this study, PM seen on CT was found to have little clinical significance other than as a marker for severe blunt trauma. No patients with airway or esophageal injuries were seen in any of the PM patients.
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Affiliation(s)
- Daniela Molena
- From the University of Rochester Medical Center, Rochester, New York
| | - Nicole Burr
- From the University of Rochester Medical Center, Rochester, New York
| | - Andrea Zucchiatti
- From the University of Rochester Medical Center, Rochester, New York
| | - Erik Lovria
- From the University of Rochester Medical Center, Rochester, New York
| | - Mark L. Gestring
- From the University of Rochester Medical Center, Rochester, New York
| | - Julius D. Cheng
- From the University of Rochester Medical Center, Rochester, New York
| | - Paul E. Bankey
- From the University of Rochester Medical Center, Rochester, New York
| | - Nicole A. Stassen
- From the University of Rochester Medical Center, Rochester, New York
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Barrios C, Malinoski D, Dolich M, Lekawa M, Hoyt D, Cinat M. Utility of Thoracic Computed Tomography after Blunt Trauma: When is Chest Radiograph Enough? Am Surg 2009. [DOI: 10.1177/000313480907501023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to identify the utility of thoracic computed tomography (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). A retrospective study was performed of 200 consecutive blunt trauma patients who received both CXR and TCT. One hundred and forty-three patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. Fifty-seven patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). TCT is of limited utility in patients with a normal admission CXR. A diagnostic strategy of obtaining TCT only in patients with abnormal CXR or high-risk mechanism of injury can result in significant cost savings without adversely affecting patient outcomes.
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Affiliation(s)
- Cristobal Barrios
- From the University of California, Irvine Medical Center, Orange, CA
| | - Darren Malinoski
- From the University of California, Irvine Medical Center, Orange, CA
| | - Matthew Dolich
- From the University of California, Irvine Medical Center, Orange, CA
| | - Michael Lekawa
- From the University of California, Irvine Medical Center, Orange, CA
| | - David Hoyt
- From the University of California, Irvine Medical Center, Orange, CA
| | - Marianne Cinat
- From the University of California, Irvine Medical Center, Orange, CA
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Time factors associated with CT scan usage in trauma patients. Eur J Radiol 2009; 72:134-8. [DOI: 10.1016/j.ejrad.2008.06.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 06/18/2008] [Indexed: 11/22/2022]
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[Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment]. Unfallchirurg 2009; 112:390-9. [PMID: 19159120 DOI: 10.1007/s00113-008-1528-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment. METHODS The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III). RESULTS The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p<0.001). The times for phase B were 70 min (IQR 56-85 min) for group I, 23 min (IQR 17-33 min) for group II and 17 min (IQR 13-21 min; p<0.001) for group III. For phase C the times were 82 min (IQR 66-110 min) for group I, 47 min (IQR 37-59 min) for group II and 42 min (IQR 34-52 min; p<0.05) for group III. CONCLUSION Quality management and the early implementation of whole-body MSCT can accelerate the treatment work flow. A rapid initial diagnosis represents an important component in the high quality of treatment of polytrauma patients.
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Wilson H, Ellsmere J, Tallon J, Kirkpatrick A. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury 2009; 40:928-31. [PMID: 19539280 DOI: 10.1016/j.injury.2009.04.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/07/2009] [Accepted: 04/14/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes. METHODS A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status-dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures. RESULTS In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p=0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p=0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces. CONCLUSION The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.
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Affiliation(s)
- Heather Wilson
- Department of Surgery (Division of General Surgery), Dalhousie University, Nova Scotia, Canada
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Routine versus selective computed tomography of the abdomen, pelvis, and lumbar spine in blunt trauma: a prospective evaluation. ACTA ACUST UNITED AC 2009; 66:1108-17. [PMID: 19359922 DOI: 10.1097/ta.0b013e31817e55c3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm. MATERIALS This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup. RESULTS Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm. CONCLUSIONS Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.
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113
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The OPTICC trial: a multi-institutional study of occult pneumothoraces in critical care. Am J Surg 2009; 197:581-6. [DOI: 10.1016/j.amjsurg.2008.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 12/16/2008] [Accepted: 12/29/2008] [Indexed: 11/18/2022]
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MDCT for automated detection and measurement of pneumothoraces in trauma patients. AJR Am J Roentgenol 2009; 192:830-6. [PMID: 19234283 DOI: 10.2214/ajr.08.1339] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The size of a pneumothorax is an important index to guide the emergency treatment of trauma patients--chest tube drainage. The purpose of this study was to develop and validate an automated computer-aided volumetry scheme for detection and measurement of pneumothoraces for trauma patients imaged with MDCT. MATERIALS AND METHODS Three pigs and 68 trauma patients with at least one diagnosed occult pneumothorax (23 women and 45 men; age range, 14-89 years; mean age, 41 +/- 19 years) were selected for the development and validation of our computer-aided volumetry scheme for pneumothorax. Computer-aided volumetry of pneumothorax consisted of five automated steps: extraction of pleural region, detection of pneumothorax candidates, delineation of the detected pneumothorax candidates, reduction of false-positive findings, and report of the volumetric measurement of pneumothoraces. RESULTS In the animal study, our computer-aided volumetry scheme yielded a mean value of 24.27 +/- 0.64 mL (SD) compared with 25 mL of air volume manually injected in each scan. The correlation coefficients were 0.999 and 0.997 for the in vivo and ex vivo comparison, respectively. In the patient study, the sensitivity of our computer-aided volumetry scheme was 100% with a false-positive rate of 0.15 per case for 32 occult pneumothoraces > or = 25 mL. The correlation coefficient was 0.999 for manual volumetry comparison. This automated computer-aided volumetry scheme took approximately 3 minutes to finish the detection and measurement per case. CONCLUSION The results show that our computer-aided volumetry scheme provides an automated method for accurate and efficient detection and measurement of pneumothoraces in MDCT images of trauma patients.
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Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time. ACTA ACUST UNITED AC 2009; 66:658-65. [PMID: 19276734 DOI: 10.1097/ta.0b013e31817de3f4] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol). METHODS Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol. RESULTS The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II. CONCLUSION A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.
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Abstract
Knowledge of the characteristics of thoraco-abdominal trauma in children is important to optimize the imaging work up while keeping radiation exposure to a minimum. Because of the plasticity of the pediatric rib cage, rib fractures are infrequent, and severe parenchymal injuries may be present in the absence of rib fracture. Mediastinal injuries are unusual. The increased mobility of solid intraabdominal organs combined with a weaker abdominal wall are specific to pediatric patients. First-line imaging typically includes chest radiograph and abdominal US with Doppler imaging. Contrast-material enhanced CT is used as a second-line technique, with delayed imaging in patients with urinary tract lesions. Dedicated pediatric acquisition protocols are mandatory. Follow-up is obtained mainly with US.
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117
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Predictors of abnormal chest CT after blunt trauma: a critical appraisal of the literature. Clin Radiol 2009; 64:272-83. [DOI: 10.1016/j.crad.2008.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 09/15/2008] [Accepted: 09/21/2008] [Indexed: 01/07/2023]
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118
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Ball CG, Ranson K, Dente CJ, Feliciano DV, Laupland KB, Dyer D, Inaba K, Trottier V, Datta I, Kirkpatrick AW. Clinical predictors of occult pneumothoraces in severely injured blunt polytrauma patients: A prospective observational study. Injury 2009; 40:44-7. [PMID: 19131061 DOI: 10.1016/j.injury.2008.07.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 07/10/2008] [Accepted: 07/29/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The supine antero-posterior (AP) chest radiograph (CXR) is an insensitive test for detecting post-traumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) that were not diagnosed on CXR. The purpose of this study was to prospectively determine the incidence, and validate previously identified clinical predictors, of OPTXs after blunt trauma. METHODS All severe blunt injured patients (injury severity score (ISS)>or=12) presenting to a level 1 trauma centre over a 17-month period were prospectively evaluated. Thoracoabdominal CT scans and corresponding CXRs were reviewed at the time of admission. Patients with OPTXs were compared to those with overt PTXs regarding incidence and previously identified predictive risk factors (subcutaneous emphysema, rib fractures, female sex and pulmonary contusion). RESULTS CT imaging was performed concurrent to CXR in 405 blunt trauma patients (ISS>or=12) during the study period. PTXs were identified in 107 (26%) of the 405 patients. Eighty-one (76%) of these were occult when CXRs were interpreted by the trauma team. Concurrent chest trauma predictive of OPTXs was limited to subcutaneous emphysema (p=0.003). Rib fractures, pulmonary contusions and female sex were not predictive. CONCLUSIONS OPTXs were missed in up to 76% of all seriously injured patients when CXRs were interpreted by the trauma team. This is higher than previously reported in retrospective studies and is likely based on the difficult conditions in which the trauma team functions. Subcutaneous emphysema remains a strong clinical predictor for concurrent OPTXs.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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Fung Kon Jin PHP, Penning N, Joosse P, Hijdra AHJ, Bouma GJ, Ponsen KJ, Goslings JC. The effect of the introduction of the Amsterdam Trauma Workflow Concept on mortality and functional outcome of patients with severe traumatic brain injury. J Neurotrauma 2008; 25:1003-9. [PMID: 18699728 DOI: 10.1089/neu.2007.0463] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The purpose of this study was to analyze the effect of the introduction of an all-in workflow concept that included direct computed tomography (CT) scanning in the trauma room on mortality and functional outcome of trauma patients with severe traumatic brain injury (TBI) admitted to a level-1 trauma center. To this end, a retrospective comparison was made of a 1-year cohort prior to the implementation of the all-in workflow concept (Pre-CT in trauma room cohort [Pre-TRCT]) and a 1-year cohort after the implementation (Post-TRCT). All severely injured TBI patients aged 16 years or older that were presented in our level-1 trauma center and that underwent a CT of the head were initially included. Severe TBI was defined as an Abbreviated Injury Scale (AIS) score of >2 of the head region following trauma. Primary outcome parameter was TBI-related mortality during primary hospital admission. Secondary outcome parameter was the functional outcome based on GOS-Extended. A total of 59 patients were included in the Pre-TRCT and 49 in the Post-TRCT. Median age was 49 years in the Post-TRCT and 44 years in the Pre-TRCT (not significant [NS]). Median ISS was similar (ISS = 25). Median Head-AIS was higher in the Post-TRCT (5 vs. 4, NS). Initial CT scanning was completed faster in the Post-TRCT. There was a significant difference of 23% mortality in favor of the Post-TRCT for TBI-related mortality during primary hospital admission (p < 0.05). For acute neurosurgical interventions, time until intervention tended to be faster in the Post-TRCT (NS). Functional outcomes for survivors were higher in the Post-TRCT (6 vs. 5, NS).
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Affiliation(s)
- P H Ping Fung Kon Jin
- Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Barrios C, Tran T, Malinoski D, Lekawa M, Dolich M, Lush S, Hoyt D, Cinat ME. Successful Management of Occult Pneumothorax without Tube Thoracostomy despite Positive Pressure Ventilation. Am Surg 2008. [DOI: 10.1177/000313480807401016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). Observation was successful in 16 of 20 occult pneumothoraces (80%) exposed to positive pressure ventilation within 72 hours of admission. Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.
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Affiliation(s)
- Cristobal Barrios
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Tuan Tran
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Darren Malinoski
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Michael Lekawa
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Stephanie Lush
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - David Hoyt
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
| | - Marianne E. Cinat
- University of California, Irvine, Department of Surgery, Division of Trauma Critical Care, Burns and Acute Care Surgery, Orange, California
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121
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Abstract
Chest computed tomography (CCT) evaluation for trauma encompasses two main objectives: (1) The evaluation of the acutely injured in the search for diagnoses and (2) follow up assessment or diagnosis of pulmonary complications in the hospitalised patient. In the acute phase of evaluation, CCT has become particularly helpful for the diagnosis of blunt thoracic aortic injury (BAI), great vessel injury, extent of lung contusion, occult hemothorax, occult pneumothorax, spinal fractures and spinal cord injuries and to determine the tract of transmediastinal gun shot wounds. In the subacute phase, CCT has gained popularity for diagnosing pulmonary embolism and evaluation of retained hemothorax. Technological advances have lead to better diagnostic capabilities that can be obtained quickly but, particularly in the trauma patient, there is little consistent data supporting an outcome improvement in the majority of patients despite changes in clinical management. Further data is needed to support use of CCT in select trauma patient populations to increase useful diagnostic yield and cost effectiveness.
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Affiliation(s)
- DS Plurad
- Division of Trauma/Surgical Critical Care University of Southern California, Los Angeles County Hospital, Los Angeles California
| | - P. Rhee
- Division of Trauma, Critical Care and Emergency Surgery, The University of Arizona, Tucson, Arizona, USA,
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122
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Traumatic pulmonary pathology measured with computed tomography and a semiautomated analytic method. Clin Imaging 2008; 32:346-54. [DOI: 10.1016/j.clinimag.2008.02.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 01/30/2008] [Indexed: 11/18/2022]
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Carpenter AJ. Diagnostic techniques in thoracic trauma. Semin Thorac Cardiovasc Surg 2008; 20:2-5. [PMID: 18420118 DOI: 10.1053/j.semtcvs.2007.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2007] [Indexed: 11/11/2022]
Abstract
Diagnosis of thoracic injury begins with a history of events and examination of the patient. Appropriate radiographic studies will be dictated by the findings on history and physical. Procedural examinations, such as endoscopy or angiography, may also be needed for accurate diagnosis.
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Affiliation(s)
- Andrea J Carpenter
- Thoracic Surgery Division, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
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124
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Hammad AMM, Regal MA. Is Routine Spiral CT-Chest Justified in Evaluation of the Major Blunt Trauma Patients? Eur J Trauma Emerg Surg 2008; 35:31-4. [DOI: 10.1007/s00068-008-8025-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Accepted: 06/11/2008] [Indexed: 11/27/2022]
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125
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Brink M, Deunk J, Dekker HM, Kool DR, Edwards MJR, van Vugt AB, Blickman JG. Added Value of Routine Chest MDCT After Blunt Trauma: Evaluation of Additional Findings and Impact on Patient Management. AJR Am J Roentgenol 2008; 190:1591-1598. [DOI: 10.2214/ajr.07.3277] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Monique Brink
- Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Internal number (Huispost) 667, Geert Groote plein 10, 6500 HB Nijmegen, The Netherlands
| | - Jaap Deunk
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Helena M. Dekker
- Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Internal number (Huispost) 667, Geert Groote plein 10, 6500 HB Nijmegen, The Netherlands
| | - Digna R. Kool
- Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Internal number (Huispost) 667, Geert Groote plein 10, 6500 HB Nijmegen, The Netherlands
| | - Michael J. R. Edwards
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Arie B. van Vugt
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Johan G. Blickman
- Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Internal number (Huispost) 667, Geert Groote plein 10, 6500 HB Nijmegen, The Netherlands
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126
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Le Guen M, Beigelman C, Bouhemad B, Wenjïe Y, Marmion F, Rouby JJ. Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: a case report. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R94. [PMID: 17767714 PMCID: PMC2556736 DOI: 10.1186/cc6109] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 07/24/2007] [Accepted: 09/03/2007] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Unnoticed bronchial injury during the early stage of resuscitation of multiple trauma is not rare and increases mortality and morbidity. METHODS Three-dimensional reconstruction of the airways using a workstation connected to a multidetector chest computed tomography (CT) scanner may change the diagnostic strategy in patients with blunt chest trauma with clinical signs evocative of bronchial rupture. RESULTS In this case report of a young motor biker, a complete disruption of the intermediary trunk was first misdiagnosed using standard chest helical CT and bronchoscopy. Postprocessing procedures including three-dimensional extraction of the tracheobronchial tree were determinants for establishing the diagnosis, and emergent surgical repair was successfully performed. Follow-up using CT with three-dimensional reconstructions evidenced a bronchial stenosis located at the site of the rupture. CONCLUSION The present study demonstrates the potential interest of performing three-dimensional reconstructions by extraction of the tracheal-bronchial tree in patients with severe blunt chest trauma suspected of bronchial rupture.
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Affiliation(s)
- Morgan Le Guen
- Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
| | - Catherine Beigelman
- Department of Radiology, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
| | - Belaid Bouhemad
- Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
| | - Yang Wenjïe
- Department of Radiology, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
| | - Frederic Marmion
- Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
| | - Jean-Jacques Rouby
- Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit Pierre Viars and the Trauma Center, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie Paris-6, France
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127
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Assessment of a New Trauma Workflow Concept Implementing a Sliding CT Scanner in the Trauma Room: The Effect on Workup Times. ACTA ACUST UNITED AC 2008; 64:1320-6. [DOI: 10.1097/ta.0b013e318059b9ae] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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128
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Abstract
PURPOSE OF REVIEW This article reviews new aspects about the significance, diagnosis and treatment of different chest injuries. RECENT FINDINGS Age and Injury Severity Score were risk factors for pneumonia and mortality in patients with rib fractures or flail chest. Occult pneumothoraces were detected in 14.5% and occult hemothoraces in 21.4% using computed tomography, whereas lung contusions were detected two times more frequently with computed tomography compared with chest X-ray. The current treatment of acute respiratory distress syndrome has been ameliorated by extracorporeal membrane oxygenation and pumpless extracorporeal lung assist system. Endovascular repair of thoracic aortic injuries has reduced mortality and morbidity compared with open repairs. Increased serum levels of troponin are related to the degree of overall injury severity and physiologic parameters but not to mechanical chest impact. The mortality of penetrating cardiac injuries is still very high (15.6% for stab wounds, 81% for gunshot wounds). SUMMARY Faster and more detailed diagnosis of thoracic injuries has been achieved by multislice computed tomography. The modern management of thoracic injuries is complex. Minimally invasive techniques (thoracoscopic surgery, endovascular repair) and recent developments in lung supportive therapies reduce mortality and morbidity. However, emergency thoracotomy is still an important and valuable approach for life-saving or damage-control procedures.
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129
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The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. ACTA ACUST UNITED AC 2008; 63:757-63. [PMID: 18090002 DOI: 10.1097/01.ta.0000235878.42251.8d] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients. METHODS Clinical and radiologic data from 106 consecutive blunt trauma patients were reviewed. Diagnoses revealed by conventional work-up of the chest, abdomen, pelvis, and thoracolumbar spine were compared with that detected by CT scan of the chest and abdomen. Unexpected findings by CT scan and rejected diagnoses by CT scan were collected. Therapeutic consequences of these diagnoses were determined both theoretically and collected from the medical records. RESULTS In 74% (95% confidence interval [CI] 65-82) of the 106 patients, 1 or more diagnoses were demonstrated by chest or abdominal CT scan, whereas they had not been revealed by preceding conventional work-up. This resulted in an actual change of treatment in 34% (95% CI 25-43) of the patients. CT scan of the chest resulted in a change of treatment in 33% (95% CI 23-44) and abdominal CT scan in 16% (95% CI 9-24). CONCLUSIONS CT scan of the chest and abdomen has a high diagnostic value in the evaluation of blunt trauma patients, when it is selectively performed in addition to the early conventional radiologic work-up. Unexpected pathologic findings are detected by CT scan in the majority of the patients. These findings result in an adaptation of treatment in a substantial number of the patients.
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130
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Wurmb TE, Frühwald P, Hopfner W, Roewer N, Brederlau J. Whole-body multislice computed tomography as the primary and sole diagnostic tool in patients with blunt trauma: searching for its appropriate indication. Am J Emerg Med 2007; 25:1057-62. [DOI: 10.1016/j.ajem.2007.03.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 01/08/2007] [Accepted: 03/18/2007] [Indexed: 11/26/2022] Open
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131
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Esme H, Kaya E, Solak O, Yavuz Y, Yurumez Y, Sezer M. Using 99mTc-DTPA radioaerosol inhalation lung scan as compared with computed tomography to detect lung injury in blunt chest trauma. Ann Nucl Med 2007; 21:393-8. [PMID: 17876552 DOI: 10.1007/s12149-007-0043-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Accepted: 05/02/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Detection of pulmonary contusion in patients with blunt chest trauma is very important so as to commence therapy immediately to avoid irreversible damage. The purpose of our study was to evaluate the efficacy of technetium-99m diethylene triamine pentaacetic acid (99mTc-DTPA) aerosol inhalation lung scintigraphy in comparison with chest computed tomography (CT) in the diagnosis of pulmonary contusion at acute blunt chest trauma. METHODS Twenty-nine patients with isolated blunt chest trauma were referred to the emergency department of our hospital, and nine healthy people participated in this study. Sixteen patients who had pulmonary contusion on CT scans were referred to as group 1, and 13 patients who had normal CT scans as group 2. Nine healthy people comprised a control group. 99mTc-DTPA aerosol inhalation lung scintigraphy was performed on the first day in all patients. RESULTS The mean half time (T1/2) and penetration index values of 99mTc-DTPA clearance were significantly lower in groups 1 and 2 compared with the control group. Among the three groups, there were no significant differences in arterial blood gas analysis except for PO2. The mean T1/2 value of 99mTc-DTPA clearance did correlate with PO2 values but not with pH, PCO2, or HCO3 values. CONCLUSIONS 99mTc-DTPA radioaerosol inhalation lung imaging may serve as a useful adjunct and supportive method to chest CT scanning for detecting mild pulmonary contusion.
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Affiliation(s)
- Hidir Esme
- Department of Thoracic Surgery, Afyon Kocatepe University, School of Medicine, Ali Cetinkaya Campus, 03200 Afyon, Turkey.
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132
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Sangster GP, González-Beicos A, Carbo AI, Heldmann MG, Ibrahim H, Carrascosa P, Nazar M, D'Agostino HB. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol 2007; 14:297-310. [PMID: 17623115 DOI: 10.1007/s10140-007-0651-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 06/15/2007] [Indexed: 10/23/2022]
Abstract
This pictorial review discusses multi-detector computed tomography (MDCT) cases of non-vascular traumatic chest injuries, with a brief clinical and epidemiological background of each of the pathology. The purpose of this review is to familiarize the reader with common and rare imaging patterns of chest trauma and substantiate the advantages of MDCT as a screening and comprehensive technique for the evaluation of these patients. Images from a level 1 trauma center were reviewed to illustrate these pathologies. Pulmonary laceration, pulmonary hernia, and their different degrees of severity are illustrated as examples of parenchymal traumatic lesions. Pleural space abnormalities (pneumothorax and hemothorax) and associated complications are shown. Diaphragmatic rupture, fracture of the sternum, sternoclavicular dislocation, fracture of the scapula, rib fracture, and flail chest are shown as manifestations of blunt trauma to the chest wall. Finally, direct and indirect imaging findings of intrathoracic airway rupture and post-traumatic foreign bodies are depicted. The advantage of high quality reconstructions, volume rendered images, and maximal intensity projection for the detection of severe complex traumatic injuries is stressed. The limitations of the initial chest radiography and the benefits of MDCT authenticate this imaging technique as the best modality in the diagnosis of chest trauma.
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Affiliation(s)
- Guillermo P Sangster
- Department of Radiology, LSUHSC-S, 1501 Kings Highway, Shreveport, LA 71130, USA.
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133
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Bernhard M, Becker TK, Nowe T, Mohorovicic M, Sikinger M, Brenner T, Richter GM, Radeleff B, Meeder PJ, Büchler MW, Böttiger BW, Martin E, Gries A. Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room. Resuscitation 2007; 73:362-73. [PMID: 17287064 DOI: 10.1016/j.resuscitation.2006.09.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 08/24/2006] [Accepted: 09/28/2006] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced. MATERIAL AND METHODS In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed. RESULTS In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25). CONCLUSION The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.
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Affiliation(s)
- Michael Bernhard
- Department of Anesthesiology and Emergency Medicine, University of Heidelberg, 110, Im Neuenheimer Feld, D-69120 Heidelberg, Germany
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134
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Abstract
Interventional radiologists (IRs) now play a major role in the management of thoracic aortic and great vessel trauma. The recent availability of a wide range of stent grafts able to treat vessels from 3 to 46 mm in diameter is clearly a significant contributor to this change. Stent grafts can now treat the majority of incomplete aortic injuries with much lower morbidity and mortality than open surgery. Short- to medium-term follow-up is encouraging, but the long-term durability is unknown, and close monitoring of these patients must continue. In great vessel trauma, stent grafts are a useful adjunct to balloon tamponade, embolization, and bare stents. As a result, a wide range of head neck and upper limb vascular injuries can be managed with less local trauma, blood loss, and physiological stress. The increased involvement of IR in the management of vascular trauma is not simply the result of technological advances. IRs have increasingly made themselves available to carry out these emergency procedures. IRs should assist in the development of trauma protocols and management algorithms that involve endovascular expertise early in the assessment of the major trauma patient.
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Affiliation(s)
- Simon J McPherson
- Department of Radiology, Leeds General Infirmary, Leeds, United Kingdom
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135
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Abstract
Significant injuries to the thorax comprise pneumothorax, rib fractures, lung contusion, cardiac contusion, aortic laceration, ruptured diaphragm, and the very rare injuries to the tracheo-bronchial tree and the esophagus. A surgeon dealing with chest trauma patients needs to be familiar with the indications for and execution of chest tube insertion for thoracic drainage, pericardial puncture, and thoracoscopy and thoracotomy. Interventional techniques are gaining increasing acceptance in the management of major vascular injuries. The vast majority of patients with chest injury do not need an operative intervention, but it is necessary to place a thoracic drain in 10-15% of cases or to perform in a much lower proportion a pericardial puncture or a thoracotomy.
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Affiliation(s)
- C Waydhas
- Klinik für Unfallchirurgie, Universitätsklinikum Essen, Hufelandstrasse 55, 45147 Essen, Deutschland.
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136
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Sharma BR, Gupta M, Bangar S, Singh VP. Forensic considerations of missed diagnoses in trauma deaths. J Forensic Leg Med 2007; 14:195-202. [PMID: 16914359 DOI: 10.1016/j.jcfm.2006.02.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 12/11/2005] [Accepted: 02/13/2006] [Indexed: 11/18/2022]
Abstract
Injuries missed at initial diagnoses or operations have the potential to cause disastrous complications in trauma patients. Understanding the etiology of unrecognized injuries is essential in minimizing its occurrence. For this purpose, we scrutinized the treatment and the autopsy records of the trauma deaths from 2000 to 2004 to determine the frequency, body regions, severity and causes of injuries that escaped recognition during the initial assessment, primary, secondary and tertiary surveys by the clinical team in patients who died of trauma. We also examined the accuracy of the cause of death as recorded on death certificates. The frequency of unrecognized injuries was found to be 11% in all trauma deaths. Abdomen (40%) and head (29%) were the more common regions of the body where injuries were frequently missed. System related errors (68%) and patient related factors (32%) were responsible for the injury remaining unrecognized. It was concluded that the injuries may be missed at any stage of the management of patients with major trauma and repeated assessments both clinical and radiological are mandatory not only to diminish the problem but to avoid litigation as well.
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Affiliation(s)
- B R Sharma
- Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, Chandigarh, India.
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137
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Lamb ADG, Qadan M, Gray AJ. Detection of occult pneumothoraces in the significantly injured adult with blunt trauma. Eur J Emerg Med 2007; 14:65-7. [PMID: 17496677 DOI: 10.1097/01.mej.0000228439.87286.ed] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Identification of pneumothoraces is essential during the initial assessment of major injury. Prompt intervention is crucial for effective resuscitation and for subsequent safe management. Historically, emergency departments have relied on chest X-ray for detection of pneumothoraces. More recently, the increasing availability of computed tomography (CT) has provided a more sensitive means of detection. Occult pneumothoraces are those that are missed on clinical examination and chest X-ray, but are detected on subsequent CT. OBJECTIVE To determine the incidence of occult pneumothoraces and their impact on subsequent management. PATIENTS All blunt trauma patients with CT scans from a single, large, adult emergency department in 1 year. METHODS Patient records were analysed to determine the proportion of pneumothoraces detected on CT that had not been previously detected on chest X-ray. Records were further examined to determine how many occult pneumothoraces required additional management after detection. RESULTS In all, 134 blunt trauma patients required a CT scan. Thirty-five pneumothoraces were detected in 27 patients; 15 were occult. Six of these 15 were managed with intercostal drain insertion, all proceeding to mechanical ventilation. Of the eight patients (one bilateral) managed observantly, all had uncomplicated recoveries. CT was significantly more sensitive in the detection of pneumothoraces (P=0.03). Retrospective review by a radiology specialist identified three chest X-rays that had findings (deep sulcus sign and prominent cardiac outline) that were suggestive of pneumothorax. CONCLUSIONS A sufficiently high proportion of pneumothoraces is missed on chest X-ray to advocate a low threshold for use of CT in the early assessment of blunt trauma patients, especially if mechanical ventilation is required for ongoing management.
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Affiliation(s)
- Alastair D G Lamb
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK.
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138
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Gavelli G, Napoli G, Bertaccini P, Battista G, Fattori R. Imaging of Thoracic Injuries. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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139
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140
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Plurad D, Green D, Demetriades D, Rhee P. The Increasing Use of Chest Computed Tomography for Trauma: Is it Being Overutilized? ACTA ACUST UNITED AC 2007; 62:631-5. [PMID: 17414339 DOI: 10.1097/ta.0b013e31802bf009] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Chest computerized tomography (CCT) has gained popularity in trauma evaluation, but it is expensive, increases exposure to radiation, and leads to findings of debatable clinical significance. The objective of this study was to determine the change in usage of CCT over time and the number of injuries missed on plain chest radiograph (CXR) with normal findings that required therapy. METHODS Data on all patients evaluated with a screening CXR during a 7-year period were extracted from a Level I center trauma registry. The incidence of CCT utilization during the duration of the study was identified. Patients who had CCT done after the initial CXR were analyzed separately for the presence of occult injuries. The association of these findings with demographic and injury data were examined. RESULTS There were 2,326 CCT performed, and 1,873 (80.5%) of them were after negative CXRs. The percentage of patients studied with CCT increased incrementally from 2.7% to 28.7% for blunt and from 0.4% to 2.9% for penetrating injury. The identification of occult pneumothorax, hemothorax, rib fractures, and lung contusions significantly increased during the study period with the increased frequency of CCT use. There were 102 occult pneumothoraces and/or hemothoraces identified, but only 12 patients underwent tube thoracostomy during the 7-year period. There were 43 patients with blunt aortic injury (BAI) and 6 (13.9%) of these patients had normal CXR findings. There was no trend in increased BAI diagnosed during the study period, although the utilization of CCT was increased. CONCLUSIONS There has been a 10-fold increase in use of CCT for trauma evaluation. Although occult findings increased, the number of patients who needed treatment was small. The excess utilization of CCT after negative CXR needs continued refinement to identify the small number of potentially lethal injuries while reducing the number of trivial findings.
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Affiliation(s)
- David Plurad
- Los Angeles County Medical Center, University of Southern California, USA
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141
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Waydhas C, Nast-Kolb D. [Chest injury. Part I: Significance--symptoms--diagnostic procedures]. Unfallchirurg 2007; 109:777-84; quiz 785. [PMID: 16941097 DOI: 10.1007/s00113-006-1149-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chest injuries can be sustained in isolation or in association with multiple injuries. Life-threatening complications may ensue because organs that are vital to survival of the organism are situated within the thoracic cavity. These complications include airway obstruction, tension pneumothorax, wide open pneumothorax, flail chest, cardiac tamponade and massive hemothorax. The mortality of patients hospitalized with chest injury can be as high as 10%. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential, and standard chest X-ray, ultrasound and thoracic computed tomography may also be needed for the diagnosis. The first part of this serial paper on the management of chest injuries focuses on anatomical aspects, pathophysiology and symptoms, but mainly on the indications for the standard diagnostic procedures and further high-tech examinations.
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Affiliation(s)
- C Waydhas
- Klinik für Unfallchirurgie, Universitätsklinikum Essen, Hufelandstrasse 55, 45147 Essen, Deutschland.
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Wisbach GG, Sise MJ, Sack DI, Swanson SM, Sundquist SM, Paci GM, Kingdon KM, Kaminski SS. What is the role of chest X-ray in the initial assessment of stable trauma patients? ACTA ACUST UNITED AC 2007; 62:74-8; discussion 78-9. [PMID: 17215736 DOI: 10.1097/01.ta.0000251422.53368.a3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness. METHODS A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period. RESULTS Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT. CONCLUSION In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.
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Affiliation(s)
- Gordon G Wisbach
- Division of Trauma, Scripps Mercy Hospital, San Diego, California 92103, USA
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143
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Traub M, Stevenson M, McEvoy S, Briggs G, Lo SK, Leibman S, Joseph T. The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury 2007; 38:43-7. [PMID: 17045268 DOI: 10.1016/j.injury.2006.07.006] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 07/06/2006] [Accepted: 07/06/2006] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. METHODS A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. RESULTS The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p<0.001), reduced air-entry (OR=4.48, 95% CI=1.33, 15.02, p=0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p=0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. CONCLUSION In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.
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Affiliation(s)
- Matthias Traub
- Trauma Service, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia
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144
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Incidence and management of occult hemothoraces. Am J Surg 2006; 192:722-6. [PMID: 17161082 DOI: 10.1016/j.amjsurg.2006.08.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 08/10/2006] [Accepted: 08/10/2006] [Indexed: 01/12/2023]
Abstract
BACKGROUND Little is known about the incidence of and associated management outcomes of occult hemothorax in blunt trauma patients. The increased use of computed thoracic tomography for the evaluation of the multiply injured blunt trauma patient has led to an increase in the identification of these hemothoraces and management dilemmas. METHODS A retrospective review of blunt trauma patients with occult hemothoraces was performed. Patients were divided into 2 groups: chest tube versus no chest tube. Outcomes and complications for the 2 groups were defined. Data included demographics, Injury Severity Score, length of stay, need for mechanical ventilation and thoracic consult, pneumonia, and empyema. The size of the occult hemothorax was measured on the computed thoracic tomography. RESULTS Eighty-eight patients (21.4%) had a total of 107 occult hemothoraces. Patients in the chest tube group were more likely to have a higher Injury Severity Score and an associated occult pneumothorax and to have smaller hemothoraces. CONCLUSIONS Occult pneumothoraces occur in a significant proportion of the multiply injured blunt trauma population. Small, isolated, occult hemothoraces can be managed safely in the stable patient.
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145
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Waydhas C, Sauerland S. Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review. Resuscitation 2006; 72:11-25. [PMID: 17118508 DOI: 10.1016/j.resuscitation.2006.06.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 06/13/2006] [Accepted: 06/20/2006] [Indexed: 02/01/2023]
Abstract
Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors' perspective.
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Affiliation(s)
- Christian Waydhas
- Department of Trauma Surgery, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
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146
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Abstract
Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.
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Affiliation(s)
- H Schelzig
- Universitätsklinik für Thorax- und Gefässchirurgie, Universität Ulm.
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147
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Atri M, Singh G, Kohli A. Chest trauma in Jammu region an institutional study. Indian J Thorac Cardiovasc Surg 2006. [DOI: 10.1007/s12055-006-0006-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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148
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Abstract
Apparently minor chest trauma may result in localized pulmonary contusion. Complications of the contusion, particularly infection, may be delayed. The association between the infection and initial injury may not be appreciated due to the time frame between the injury and clinical presentation. We report two cases of low-moderate impact pulmonary trauma resulting in focal pulmonary contusion, complicated by infection.
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Affiliation(s)
- G M Hafen
- Royal Children's Hospital, Respiratory Department, Flemington Rjoad, Victoria, Australia.
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149
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Affiliation(s)
- Mathew W Lively
- Department of Medicine, West Virginia University, Morgantown, WV 26506, USA.
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150
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Abstract
Chest radiographs frequently underestimate the severity and extent of chest trauma and, in some cases, fail to detect the presence of injury. CT is more sensitive than chest radiography in the detection of pulmonary, pleural, and osseous abnormalities in the patient who has chest trauma. With the advent of multidetector CT (MDCT), high-quality multiplanar reformations are obtained easily and add to the diagnostic capabilities of MDCT. This article reviews the radiographic and CT findings of chest wall, pleural, and pulmonary injuries that are seen in the patient who has experienced blunt thoracic trauma.
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Affiliation(s)
- Lisa A Miller
- Department of Radiology, ShockTrauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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