201
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Affiliation(s)
- Hans-Christoph Pape
- Department of Orthopaedic Surgery, Division Chief-Traumatology, Suite 911, Kaufmann Med. Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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202
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Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib Fracture Stabilization in Patients Sustaining Blunt Chest Injury. Am Surg 2006; 72:307-9. [PMID: 16676852 DOI: 10.1177/000313480607200405] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Conservative management for the majority of patients with severe chest injuries has produced a reduction in mortality, complications, and hospital length of stay. More recently, operative stabilization of rib fractures has been used with the implication of improved outcome. We assessed the impact of operative rib fracture stabilization on outcome among trauma patients. A matched case-control study of patients undergoing operative rib fracture stabilization was performed. Thirty patients undergoing rib stabilization were matched with 30 controls. Length of intensive care unit (controls, 14.1 ± 2.7 vs cases, 12.1 ± 1.2, P = 0.51) and total hospital (controls, 21.1 ± 3.9 vs cases, 18.8 ± 1.8, P = 0.59) stay were similar for both groups. There was a trend toward fewer total ventilator days for operative patients (6.5 ± 1.3 days vs 11.2 ± 2.6 days, P = 0.12). Ventilator days for operative patients from the time of stabilization was 2.9 ± 0.6 days compared with 9.4 ± 2.7 days in controls (P = 0.02). Rib fracture fixation may reduce ventilator requirements in trauma patients with severe thoracic injuries. Long-term functional outcomes need to be assessed to ascertain the impact of this procedure.
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Affiliation(s)
- Ram Nirula
- Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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203
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Perl M, Gebhard F, Braumüller S, Tauchmann B, Brückner UB, Kinzl L, Knöferl MW. The pulmonary and hepatic immune microenvironment and its contribution to the early systemic inflammation following blunt chest trauma. Crit Care Med 2006; 34:1152-9. [PMID: 16484915 DOI: 10.1097/01.ccm.0000207343.53990.a8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blunt chest trauma is accompanied by an early increase in plasma cytokine concentrations. However, the local sources of these mediators are poorly defined. We investigated the impact of blunt chest trauma on the inflammatory mediator milieu in different compartments (lung tissue, bronchoalveolar lavage, liver tissue, Kupffer cells, plasma) along with the time course of trauma-induced pulmonary endothelial barrier dysfunction to elucidate potential relationships. In addition, the correlation between intratracheally instilled interleukin-6 and its systemic release were studied. DESIGN Prospective, randomized, controlled animal study. SETTING Basic science laboratory of a university affiliated level 1 trauma center. SUBJECTS Male C3H/HeN mice, 8-9 wks old, n = 141. INTERVENTIONS Blunt chest trauma induced by a focused blast wave, intravenous injection of Evans blue, and intratracheal instillation of recombinant human interleukin-6. MEASUREMENTS AND MAIN RESULTS Two hours after blunt chest trauma, plasma interleukin-6 was markedly increased. Simultaneously, interleukin-6, tumor necrosis factor-alpha, macrophage inflammatory protein-2, monocyte chemotactic polypeptide-1 and neutrophil/monocyte accumulation in bronchoalveolar lavage and interleukin-6, monocyte chemotactic polypeptide-1, and myeloperoxidase activity in lung tissue were significantly increased. This was accompanied by a coinciding elevation in the Evans blue lung-plasma ratio. Recombinant human interleukin-6, instilled intratracheally before blunt chest trauma, was detected in a dose-dependent manner in the plasma of the mice. Additionally, Kupffer cell interleukin-6, tumor necrosis factor-alpha, and interleukin-10 production was significantly augmented as early as 30 mins after the insult. CONCLUSIONS These results indicate that early increased cytokine concentrations in the lung, particularly interleukin-6, are important mediator sources as their local peak coincides with the systemic inflammatory response and is accompanied by a simultaneous impaired function of the pulmonary endothelial barrier. A direct relationship between their local and systemic concentrations can be established. Furthermore, this is the first study to show that Kupffer cells are activated early after blunt chest trauma.
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Affiliation(s)
- Mario Perl
- Department of Trauma, Hand, Plastic, and Reconstructive Surgery, University of Ulm, Germany
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204
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Ihama Y, Miyazaki T, Ageda S, Arao T, Fuke C. An Autopsy Case of Heart Rupture From a Scooter Accident With 3 Riders. Am J Forensic Med Pathol 2006; 27:87-9. [PMID: 16501358 DOI: 10.1097/01.paf.0000202808.85644.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 15-year-old male died of cardiac rupture due to blunt chest trauma from a traffic accident involving a low-speed scooter carrying 3 people and a head-on collision with a tree. The victim was sitting on the footrest of the scooter. It was concluded that the victim was compressed between the handlebar of the scooter and the other 2 passengers, causing cardiac ruptures via bidirectional compression and intravascular hydrostatic pressure. The victim may have served as a cushion for the other 2 passengers, who were not thrown from the scooter and sustained only minor injuries.
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Affiliation(s)
- Yoko Ihama
- Department of Forensic Medical Science, Graduate School of Medicine, University of the Ryukyus, Okinawa.
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205
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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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206
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Kerut EK, Kelley G, Falco VC, Ovella T, Diethelm L, Helmcke F. Traumatic deceleration injury of the thoracic aorta. Echocardiography 2005; 22:697-704. [PMID: 16174130 DOI: 10.1111/j.1540-8175.2005.40150.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Edmund Kenneth Kerut
- Department of Pharmacology, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70072, USA.
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207
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208
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Lu LH, Choi WM, Wu HR, Liu HC, Chiu WT, Tsai SH. Blunt Cardiac Rupture with Prehospital Pulseless Electrical Activity: A Rare Successful Experience. ACTA ACUST UNITED AC 2005; 59:1489-91. [PMID: 16394928 DOI: 10.1097/01.ta.0000195876.14962.24] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Blunt cardiac rupture is highly associated with mortality. In the recent literature, the reported mortality rates of cardiac rupture ranged from 59.7% to 100%. The probability of survival for those with prehospital pulseless electrical activity was extremely low. This case report describes a rare example of survival of a female patient with life-threatening cardiac rupture and cardiac tamponade after a major car accident. The victim developed pulseless electrical activity at admission. She recovered from the accident, however, without developing any signs of neurologic deficits. This case study emphasizes the value of the primary survey of patients and prompt and accurate interventions, including focused abdominal sonography for trauma, pericardiocentesis, and an urgent thoracotomy in the operating room for primary repair of cardiac rupture without applying a cardiopulmonary bypass system. The study showed that early diagnosis and aggressive interventions are crucial factors to the successful outcome of patient's survival.
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Affiliation(s)
- Li-Hua Lu
- Department of Emergency Medicine, Mackay Memorial Hospital, Mackay Junior College of Nursing, Taipei, Taiwan, Republic of China
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209
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Han S, Baldemir M, Kose SK, Erdem D, Sakinci U. The Time Course of Recovery Following Mild Thoracic Trauma. Heart Lung Circ 2005; 14:252-4. [PMID: 16360995 DOI: 10.1016/j.hlc.2005.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2004] [Revised: 03/31/2005] [Accepted: 04/15/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study was to determine when patients are able to return to their normal work or home activities. PATIENTS AND METHODS Eighty cases, 35 females (44%) and 45 males (56%), presenting to our hospital between the years of 2003 and 2004 were prospectively evaluated. There were no hemopneumothorax or associated injury. The patients were randomized into two groups with respect to treatment modalities as the following: non-steroid anti-inflammatory (NSAIDs) and Tramadol treatment groups. In the follow-up, visual analog scale (VAS), and vital capacity were conducted on the days 0, 2, 7 and 30 and 6 months. The results were statistically analyzed. RESULTS The mean age of the group receiving NSAIDs was 55.42 +/- 15.72, and for the group receiving tramadol treatment, it was 55.67 +/- 17.23. VAS result was 7.8 +/- 1.8 in those receiving NSAIDs treatment, while it was 8.2 +/- 1.6 in the other group. The vital capacity was 235.54 +/- 82 ml for the former group, and 232.43 +/- 89.44 for the latter. In their follow-up, particularly by the 7th day, significant improvement of VAS and vital capacity were observed (p < 0.01). Maximum improvement was achieved on the 30th day (p < 0.001). There was no change in the 6th month. CONCLUSION Patients are able to return to their normal work or home activities after 7 days. Patients experienced steadily decreasing pain and improved vital capacity at each time point after injury. No difference in response was seen between the two medications. A significant improvement is observed by the 7th day after the trauma (p < 0.01). Optimal improvement was achieved on the 30th day (p < 0.001).
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Affiliation(s)
- Serdar Han
- Ankara Numune Education and Research Hospital, Department of Thoracic Surgery, Metis Doruk Sitesi D Blok no: 8 Keklikpinari Dikmen, Ankara, Turkey.
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210
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Raghavendran K, Davidson BA, Helinski JD, Marschke CJ, Manderscheid P, Woytash JA, Notter RH, Knight PR. A rat model for isolated bilateral lung contusion from blunt chest trauma. Anesth Analg 2005; 101:1482-1489. [PMID: 16244015 DOI: 10.1213/01.ane.0000180201.25746.1f] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Lung contusion affects 17%-25% of adult blunt trauma patients, and is the leading cause of death from blunt thoracic injury. A small animal model for isolated bilateral lung contusion has not been developed. We induced lung contusion in anesthetized rats by dropping a 0.3-kg weight onto a precordial protective shield to direct the impact force away from the heart and toward the lungs. Lung injury was characterized as a function of chest impact energy (1.8-2.7 J) by measurements of arterial oxygenation, bronchoalveolar lavage (BAL) albumin and cytology, pressure-volume mechanics, and histopathology. Histology confirmed bilateral lung contusion without substantial cardiac muscle trauma. Rats receiving 2.7 J of chest impact energy had 33% mortality that exceeded prospectively defined limits for sublethal injury. Hypoxemia in rats with maximal sublethal injury (2.45 J) met criteria for acute lung injury at < or =24 h, improving by 48 h. BAL albumin levels were highest at < or =24 h, and remained elevated along with increased BAL leukocytes and decreased lung volumes at 48 h. We concluded that an impact energy of 2.45 J induces isolated, bilateral lung contusion and provides a useful model for future mechanistic pathophysiological assessments.
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Affiliation(s)
- Krishnan Raghavendran
- Departments of *Surgery, †Anesthesiology, and ‡Pathology, State University of New York (SUNY) at Buffalo, Buffalo; and §Department of Pediatrics, University of Rochester, Rochester, New York
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211
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Bushby N, Fitzgerald M, Cameron P, Marasco S, Bystrzycki A, Rosenfeld JV, Bailey M. Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma. Emerg Med Australas 2005; 17:443-9. [PMID: 16302936 DOI: 10.1111/j.1742-6723.2005.00775.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with 'unexpected survival'. This study used TRISS analysis to identify 'unexpected survivors' suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to 'unexpected survival'. METHODS The present study was a single-centre, retrospective case review with comparative statistical analysis. Patients were identified from the Alfred Trauma Registry between 1 July 2002 and 30 June 2003. RESULTS There were 336 adult trauma patients treated at The Alfred Trauma Centre with an Injury Severity Score >15 (major trauma) and at least one thoracic Anatomical Injury Score of 3 (severe) or greater. Of the eligible patients, 322/336 (95.8%, 95%[confidence interval] CI 95.1-96.5%) had complete data available for analysis. The study population mortality was 42/322 (13.0%, 95% CI 12.3-13.7%). There were 20 'unexpected survivors' (5.9%) and 5 (1.5%) 'unexpected deaths' on TRISS analysis. Chest decompression and/or endotracheal intubation prehospital was performed on 16/20 'unexpected survivors'. GCS for 'unexpected survivors' and 'expected deaths' (3.8 vs 3.5, P = 0.27) was not a predictor of survival. Respiratory rate per minute (16.2 vs 8.8, P = 0.01) and systolic blood pressure - mmHg (98 vs 80, P = 0.03) were significantly greater in the 'unexpected survivors' group compared with the 'expected death' group. CONCLUSION For patients sustaining severe thoracic blunt trauma, prehospital intubation and chest decompression appear to be associated with unexpected survival. A low GCS at scene is not predictive of 'unexpected survival' or 'expected death'.
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Affiliation(s)
- Nathan Bushby
- Emergency and Trauma Centre, The Alfred, Prahran, Victoria, Australia.
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212
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Ball CG, Kirkpatrick AW, Laupland KB, Fox DI, Nicolaou S, Anderson IB, Hameed SM, Kortbeek JB, Mulloy RR, Litvinchuk S, Boulanger BR. Incidence, Risk Factors, and Outcomes for Occult Pneumothoraces in Victims of Major Trauma. ACTA ACUST UNITED AC 2005; 59:917-24; discussion 924-5. [PMID: 16374282 DOI: 10.1097/01.ta.0000174663.46453.86] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The supine anteroposterior chest radiograph (CXR) is an insensitive test for posttraumatic pneumothoraces (PTXs). Computed tomographic (CT) scanning often detects PTXs that were not diagnosed on CXR (occult PTXs [OPTXs]). The purpose of this study was to define the incidence, predictors, and outcomes for OPTXs after trauma. METHODS Thoracoabdominal CT scans and corresponding CXRs of all trauma patients entered into a regional database were reviewed. Patients with OPTXs were compared with those with overt, residual, and no PTXs regarding incidence, demographics, associated injuries, early resuscitative predictors, treatment, and outcomes. RESULTS Paired CXRs and CT scans were available for 338 of 761 (44%) patients (98.5% blunt trauma). One hundred three PTXs were present in 89 patients, 57 (55%) of which were occult; 6 (11%) were seen only on thoracic CT scan. Age, sex, length of stay, and survival were similar between all groups. OPTXs and PTXs were similar in comparative size index and number of images. Subcutaneous emphysema, pulmonary contusion, rib fracture(s), and female sex were independent predictors of OPTXs. Seventeen (35%) patients with OPTXs were ventilated, of whom 13 (76%) underwent thoracostomy. No complications resulted from observation, although 23% of patients with thoracostomy had tube-related complications or required repositioning. CONCLUSION OPTXs are commonly missed both by CXR and even abdominal CT scanning in seriously injured patients. Basic markers available early in resuscitation are highly predictive for OPTXs and may guide management before CT scanning. Further study of OPTX detection and management is required.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
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213
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Abstract
Chest radiography remains the primary screening study for the assessment of victims of chest trauma, but computed tomography (CT), particularly multidetector CT (MDCT), has progressively changed the imaging approach to these patients. MDCT acquires thinner sections with greater speed, allowing higher quality axial images and nonaxial reformations than conventional or single-detector helical CT. The speed of MDCT, both in acquiring data and in reconstructing images, makes the performance of total body surveys in the blunt polytrauma patient practicable. In general, CT has been well documented to offer major advantages over chest radiography in both screening for thoracic injuries and in characterizing such injuries. This capacity has been enhanced by the application of multichannel data acquisition. The greater sensitivity of MDCT has been well demonstrated in diagnosing vascular and diaphragmatic injuries. This article reviews current concepts of diagnostic imaging in acute chest trauma from blunt force and penetrating mechanisms emphasizing the spectrum of diagnostic imaging findings for various injuries, based primarily on radiographic and CT appearances. The advantages of MDCT for selected injuries are emphasized.
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Affiliation(s)
- Stuart E Mirvis
- Department of Diagnostic Radiology and Maryland Shock-Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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214
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A case of blunt injury to the superior vena cava and right atrial appendage: Mechanisms of injury and review of the literature. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.injury.2005.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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215
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Wall MJ, Mattox KL, Wolf DA. The Cardiac Pendulum: Blunt Rupture of the Pericardium with Strangulation of the Heart. ACTA ACUST UNITED AC 2005; 59:136-41; discussion 141-2. [PMID: 16096553 DOI: 10.1097/01.ta.0000171466.47885.c5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blunt injury of the pericardium with strangulation of the heart is a rare clinical injury. METHODS We conducted a review of clinical records and performed prospective collection of forensic data from a large urban medical examiner's office. RESULTS Ten cases of blunt injury to the pericardium were identified. All were secondary to blunt trauma. Nine of the 10 cases had associated chest wall injuries and 5 of the 10 cases had cardiac strangulation. CONCLUSION Pericardial lacerations are common findings at autopsy. Clinically, those that survive to the hospital have a confusing presentation. They are often diagnosed during emergent thoracotomy for hemodynamic instability. Hemodynamic deterioration associated with change in patient position may be a clue to cardiac strangulation.
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Affiliation(s)
- Matthew J Wall
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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216
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Kuhne CA, Kaiser GM, Flohe S, Beiderlinden M, Kuehl H, Stavrou GA, Waydhas C, Lendemanns S, Paffrath T, Nast-Kolb D. Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients. Surg Today 2005; 35:518-23. [PMID: 15976946 DOI: 10.1007/s00595-005-3001-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2004] [Accepted: 11/16/2004] [Indexed: 12/27/2022]
Abstract
PURPOSE A rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure. METHODS We retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR). RESULTS Five (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury. CONCLUSION We believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.
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217
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Perl M, Gebhard F, Brückner UB, Ayala A, Braumüller S, Büttner C, Kinzl L, Knöferl MW. Pulmonary contusion causes impairment of macrophage and lymphocyte immune functions and increases mortality associated with a subsequent septic challenge*. Crit Care Med 2005; 33:1351-8. [PMID: 15942355 DOI: 10.1097/01.ccm.0000166352.28018.a9] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE AND DESIGN Pulmonary contusion is frequently followed by acute respiratory distress syndrome, pneumonia, and sepsis. However, immunologic alterations of circulating and resident immune cell populations contributing to the posttraumatic immunosuppression are poorly understood. We therefore characterized the influence of pulmonary contusion on peripheral blood mononuclear cells, peritoneal macrophages, splenocytes, and splenic macrophages. To address the significance of the immunosuppression associated with lung contusion, we investigated how the consecutive addition of moderate or severe sepsis affected survival after blunt chest trauma. SUBJECTS Male C3H/HeN mice (n = 10 per group) were anesthetized and subjected to chest trauma or sham procedure. MEASUREMENTS The cytokine release of cultured peripheral blood mononuclear cells, peritoneal macrophages, splenocytes, and splenic macrophages and plasma levels of tumor necrosis factor-alpha and interleukin-6 from those animals were quantified. Sepsis was induced via cecal ligation and puncture 24 hrs after lung contusion. MAIN RESULTS Two hours after blunt chest trauma, plasma tumor necrosis factor-alpha and interleukin-6 were markedly increased, as was peripheral blood mononuclear cell cytokine production, lung myeloperoxidase activity, and lung chemokine concentrations. At 24 hrs and, in part, already at 2 hrs, cytokine release from peritoneal macrophages, splenic macrophages, and splenocytes was significantly suppressed. Furthermore, pulmonary contusion when followed by moderate sepsis significantly diminished survival rate when compared with chest trauma or moderate sepsis alone. CONCLUSIONS These results indicate that pulmonary contusion causes severe immunodysfunction of splenocytes, macrophages, and monocytes in different local compartments and systemically. Moreover, this immunosuppression is associated with an increased susceptibility to infectious complications, which results in a decreased survival rate if blunt chest trauma is followed by a septic insult.
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Affiliation(s)
- Mario Perl
- Department of Trauma, Hand, and Reconstructive Surgery, University of Ulm, Germany
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218
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Ball CG, Peddle S, Way J, Mulloy RH, Nixon JA, Hameed SM. Blunt Cardiac Rupture: Isolated and Asymptomatic. ACTA ACUST UNITED AC 2005; 58:1075-7. [PMID: 15920429 DOI: 10.1097/01.ta.0000085644.79553.b1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Chad G Ball
- Foothills Hospital, University of Calgary, Calgary, Alberta, Canada.
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219
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Weber P, Vastmans J, Gärtner C, van Boemmel T, Hofmann GO. [Bronchial rupture combined with luxation fracture of the thoracic spine following direct trauma]. Unfallchirurg 2005; 107:1093-8. [PMID: 15292957 DOI: 10.1007/s00113-004-0792-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tracheobronchial injuries in blunt thoracic trauma are very rare (incidence: under 1%), with potentially devastating consequences. Appropriate pre-, intra-, and postoperative management is mandatory to ensure the patient's survival and maintain lung function. We report the case of a 62-year-old male patient hit by a tree over the chest while cutting down trees, suffering a rupture of the right bronchus and a tear of the trachea combined with a luxation fracture of the thoracic spine between Th2 and Th3 (without neurological deficit). With immediate suture of the torn bronchus and trachea and stabilization of the spine fracture on the following day, we achieved a successful outcome in this patient. To our knowledge, this is the first description in the literature of the combination of both injuries.
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Affiliation(s)
- P Weber
- Berufsgenossenschaftliche Unfallklinik Murnau
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220
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Virgós Señor B, Nebra Puertas AC, Sánchez Polo C, Broto Civera A, Suárez Pinilla MA. [Predictors of outcome in blunt chest trauma]. Arch Bronconeumol 2005. [PMID: 15530340 DOI: 10.1016/s1579-2129(06)60363-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Thoracic trauma is often associated with polytrauma. Because mortality is high, the search for prognostic tools is useful. PATIENTS AND METHODS A total of 108 patients with blunt thoracic trauma, 73 of whom had multiple injuries, were studied in an intensive care unit (ICU). The variables named as potential predictors of outcome were the need for mechanical ventilation, duration of ventilation, and high positive end-expiratory pressure (PEEP); the presence of rib fractures, pulmonary contusion, pleural involvement (hemo- and/or pneumothorax), or lung infection; the need for emergency surgery; mean duration of ICU stay, and age. We also studied whether or not the mortality rate was higher in polytrauma patients. Student t and chi2 tests (95% confidence level) and multiple regression analysis (Hosmer-Lemeshow goodness of fit) were used to analyze the results. RESULTS The need for mechanical ventilation, radiographic evidence of pulmonary contusion, emergency surgery, and hemodynamic instability were risk factors for increased mortality. Higher risk of mortality was not demonstrated for patients with multiple injuries. For patients in need of mechanical ventilation, high PEEP was a predictor of poor prognosis. CONCLUSIONS The presence of the aforementioned predictors (mechanical ventilation, high PEEP, pulmonary contusion, emergency surgery, and hemodynamic instability) indicate serious injury to the lung parenchyma, which is the main determinant of outcome for patients with thoracic trauma.
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Affiliation(s)
- B Virgós Señor
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain.
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221
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Abstract
O pseudocisto pulmonar traumático é uma lesão rara resultante de trauma torácico fechado. A infecção secundária é uma complicação incomum, mas com grande morbidade, devendo ser tratada precocemente. Um paciente do sexo masculino, de 28 anos, vítima de acidente de motocicleta, apresentou na internação hemoptóicos, dor torácica, dispnéia e hipoxemia. A tomografia computadorizada de tórax mostrou infiltrado pulmonar associado a imagens císticas em lobo inferior direito. Evoluiu com febre, expectoração purulenta e nível hidro-aéreo em pseudocistos de lobo inferior direito. Foi iniciado esquema antibiótico de amplo espectro após coleta de culturas, com melhora clínica e alta hospitalar após quinze dias.
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222
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Abstract
BACKGROUND Chest injuries are seen with increasing frequency in urban hospitals. The profile of chest injuries depends on the size of the hospital and the level of trauma center. The data regarding the true incidence of chest trauma are scant. METHODS One thousand three hundred fifty-nine consecutive patients seen at a Level I trauma center were analyzed. The nature of injury, methods of treatment, and morbidity and mortality were recorded in a prospective manner and analyzed retrospectively. Multiple logistic regression analysis was used to determine the independent predictors of mortality after chest trauma. RESULTS The overall mortality was 9.41%. Low Glasgow Coma Scale score, older age, presence of penetrating chest injury, long bone fractures, fracture of more than five ribs, and liver and spleen injuries were independent predictors of death after chest trauma. A model was created for predicting the mortality based on various factors. CONCLUSION Most chest injuries can be treated with simple observation. Only 18.32% of patients required tube thoracostomy and 2.6% needed thoracotomy. Low Glasgow Coma Scale score and advanced age are the most significant independent predictors of mortality.
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Affiliation(s)
- Pankaj Kulshrestha
- Department of Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
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223
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Abstract
In recent years, the advent of multidetector CT (MDCT) has begun to change the imaging approach to patients sustaining blunt or penetrating thoracic injury. The ability to directly detect some injuries that are often occult on chest radiography, such as pericardial hemorrhage, major thoracic vascular injury, small pneumothorax, and diaphragm tears, as well as the ability to better define the extent of other injuries, such as lung contusion and laceration, account for this transition. This article reviews current concepts of diagnostic imaging in acute chest trauma from both blunt force and penetrating mechanisms, emphasizing the spectrum of diagnostic imaging findings for various injuries, primarily based on multidetector MDCT.
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Affiliation(s)
- Stuart E Mirvis
- Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore 21201, USA.
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224
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Knöferl MW, Liener UC, Perl M, Brückner UB, Kinzl L, Gebhard F. BLUNT CHEST TRAUMA INDUCES DELAYED SPLENIC IMMUNOSUPPRESSION. Shock 2004; 22:51-6. [PMID: 15201702 DOI: 10.1097/01.shk.0000127684.64611.5c] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe blunt chest trauma is frequently associated with multiple organ failure and sepsis. Posttraumatic immunosuppression seems to play a major role in their development. However, the immunologic alterations following pulmonary contusion are insufficiently elucidated. Specifically, it remains unknown whether immunocompetent cells located distant from the site of the impact are affected. We therefore aimed to characterize the influence of pulmonary contusion on lymphocytes and splenic macrophages. Male C3H/HeN mice (n = 8-10/group) were anesthetized and subjected to trauma or sham procedure. Blunt chest trauma was induced by a blast wave focused on the thorax. Two or 24 h later, splenocytes and splenic macrophages were isolated and stimulated for 48 h. The cytokine release (IFN-gamma, IL-2, IL-3, IL-10, IL-12, IL-18) from splenocytes as well as from splenic macrophages (TNF-alpha, IL-10, IL-12, IL-18) and plasma levels of TNF-alpha and IL-6 were quantified by ELISA. The results indicate that at 2 h after blunt chest trauma, plasma TNF-alpha and IL-6 were markedly increased. At the same time, no differences in splenocyte cytokine production were detectable. However, at 24 h a significantly depressed cytokine release was observed in trauma animals. Furthermore, splenic macrophages showed a significantly decreased production of TNF-alpha, IL-10, and IL-12 at 24 h and markedly increased release of IL-18 at 2 h after trauma. These results indicate that blunt chest trauma causes severe immunodysfunction of lymphocytes and splenic macrophages. Thus, lung contusion as a localized type of trauma causes dysfunction of immunocompetent cell populations, which are located distant from the site of injury.
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Affiliation(s)
- Markus W Knöferl
- Department of Trauma, Hand and Reconstructive Surgery, University of Ulm, 89075 Ulm, Germany.
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225
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Affiliation(s)
- Riyad Karmy-Jones
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
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226
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Abstract
Thoracic trauma remains a major source of morbidity and mortality in injured children, and is second only to brain injuries as a cause of death. The presence of a chest injury increases an injured child's mortality by 20-fold. Greater than 80% of chest injuries in children are secondary to blunt trauma. The compliant chest wall in children makes pulmonary contusions and rib fractures the most common chest injuries in children. Injuries to the great vessels, esophagus, and diaphragm are rare. Failure to promptly diagnose and treat these injuries results in increased morbidity and mortality.
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Affiliation(s)
- Kennith H Sartorelli
- From the Department of Surgery, Division of Pediatric Surgery, University of Vermont, Burlington, VT 05401, USA
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227
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Turhan H, Topaloglu S, Cagli K, Sasmaz H, Kutuk E. Traumatic type B aortic dissection causing near total occlusion of aortic lumen and diagnosed by transthoracic echocardiography: A case report. J Am Soc Echocardiogr 2004; 17:80-2. [PMID: 14712193 DOI: 10.1016/j.echo.2003.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A true dissection of the descending thoracic aorta resulting from blunt chest trauma is a relatively rare injury compared with aortic transsection and occurs mostly in the region of the aortic isthmus. It is a life-threatening condition that requires rapid and accurate diagnosis. In this case, we report a patient with Stanford type B aortic dissection caused by decelerating trauma of the chest in a motor vehicle accident causing near total occlusion of the aortic lumen. The diagnosis was made by transthoracic echocardiography and confirmed by aortography.
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Affiliation(s)
- Hasan Turhan
- Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey.
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228
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Abstract
Blunt thoracic trauma can result in significant morbidity in injured patients. Both chest wall and the intrathoracic visceral injuries can lead to life-threatening complications if not anticipated and treated. Pain control, aggressive pulmonary toilet, and mechanical ventilation when necessary are the mainstays of supportive treatment. The elderly with blunt chest trauma are especially at risk for pulmonary deterioration in the several days postinjury and should be monitored carefully regardless of their initial presentation. Blunt thoracic trauma is also a marker for associated injuries, including severe head and abdominal injuries.
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Affiliation(s)
- Sandra Wanek
- Division of General Surgery, Oregon Health & Science University, Mail Code L223A, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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229
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Aufmkolk M, Ruchholtz S, Hering M, Waydhas C, Nast-Kolb D. [The value of subjective estimation of the severity of thoracic injuries by the emergency surgeon]. Unfallchirurg 2004; 106:746-53. [PMID: 14631530 DOI: 10.1007/s00113-003-0640-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTENTION Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in cases without acute respiratory dysfunction. Due to the possible life threatening complications of the therapy, the emergency surgeon should be able to correctly identify a TT at the scene. Therefore, we retrospectively compared the evaluation of chest trauma by the emergency surgeon with objective injury severity according to the Abbreviated Injury Scale (AIS). METHOD Data from 2,392 patients (aged 39+/-1 years, Injury Severity Score 27+/-0.3) were taken from the multiple trauma database of the German Trauma Society. The evaluation of TT (absent, light, medium, severe) by the emergency surgeon was compared with objective injury severity (AIS=0: absent, 0>AIS<3: light, AIS=3: medium, AIS>3: severe). If the difference between the subjective and objective injury severity increased or decreased two and more levels, a substantial misclassification was assumed. The influence of the estimate on outcome was tested by comparing the predicted (TRISS-method) with the observed fatalities. RESULTS Absence of TT was estimated correctly in 62%, light in 24%, medium in 40% and severe TT in 46% of cases. Thus a correct estimate of TT was made for 49% of the patients. The chest injury severity was substantially overrated by the emergency surgeon in 20% and substantially underestimated in 17% of cases. In patients with the correct classification at the scene, a total of 81% received a chest tube. Of these patients, only 50% received their chest tube at the scene. Of the patients with an initially overlooked TT, only 37% received a chest tube and nearly all were placed in the emergency room. The number of fatalities was lower than predicted in all groups, even in patients with correctly estimated severe TT (observed: 34%, estimated: 42+/-2%), and also in patients with initially overlooked TT (observed: 16%, estimated: 24+/-2%). CONCLUSION Due to the high rate of misclassification and possible severe complications caused by therapy, and without having any benefit in terms of outcome, intubation and chest tube insertion should not be carried out in vital, stable patients.
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Affiliation(s)
- M Aufmkolk
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinik Essen, Essen.
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230
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Virgós Señor B, Nebra Puertas A, Sánchez Polo C, Broto Civera A, Suárez Pinilla M. Marcadores pronósticos en los pacientes con traumatismo torácico cerrado. Arch Bronconeumol 2004. [DOI: 10.1016/s0300-2896(04)75579-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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231
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Abstract
In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging
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Affiliation(s)
- Jess M Schultz
- Department of Surgery, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, L223, Portland, OR 97239, USA
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232
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Fang R, Miller OL, Cai T, Kupferschmid JP, Stewart RM. Blunt Avulsion of the Right Inferior Pulmonary Vein. ACTA ACUST UNITED AC 2004; 56:191-3. [PMID: 14749589 DOI: 10.1097/01.ta.0000103993.29617.a9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Raymond Fang
- Department of Surgery, Wilford Hall Medcial Center, Lackland Air Force Base, San Antonio, TX, USA
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233
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Hoth JJ, Scott MJ, Bullock TK, Stassen NA, Franklin GA, Richardson JD. Thoracotomy for Blunt Trauma: Traditional Indications May Not Apply. Am Surg 2003. [DOI: 10.1177/000313480306901218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The indications for performing as urgent thoractomy after trauma are based on the criteria used for penetrating injuries. However, few data are available on the use of these indications for patients with blunt injuries. In a retrospective study (June 1996 to July 2001), we compared the indications of urgent thoracotomy after blunt injury and penetrating injury in patients who underwent thoracotomy within 24 hours of hospital admission at our institution. Patients with blunt aortic injuries or emergency department thoracotomies were excluded from evaluation. Fifty-nine patients were identified (37 penetrating injuries, 22 blunt injuries). Blunt trauma victims had a higher mortality rate than penetrating trauma victims (73% vs. 22%). Chest tube output was the indication for nontherapuetic thoracotomy in 5 patients with blunt injuries whereas this occurred in only 1 penetrating injury victim (P = 0.04). All 5 blunt injury patients underwent a prior procedure and were coagulopathic when thoracotomy was performed. In conclusion, tho-racotomy following blunt trauma is associated with a high rate of mortality. The rate of non-therapeutic exploration is increased when chest tube output is the indication for thoracotomy after blunt trauma. Since the majority of such patients have multicavitary injuries that require prior operation and are commonly coagulopathic, caution should be exercised when deciding whether to proceed with thoracotomy based solely on chest tube output.
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Affiliation(s)
- Jason J. Hoth
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
| | - Melanie J. Scott
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
| | - Timothy K. Bullock
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
| | - Nicole A. Stassen
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
| | - Glen A. Franklin
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
| | - J. David Richardson
- Department of Surgery, University of Louisville School of Medicine; and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Kentucky
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234
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Liener UC, Knöferl MW, Sträter J, Barth TFE, Pauser EM, Nüssler AK, Kinzl L, Brückner UB, Gebhard F. Induction of Apoptosis Following Blunt Chest Trauma. Shock 2003; 20:511-6. [PMID: 14625474 DOI: 10.1097/01.shk.0000095057.62263.fb] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The cause for the high morbidity of blunt chest trauma is not fully understood. It is still unclear if and to what extent a second insult, e.g., apoptotic tissue damage initiated by the primary insult itself, may contribute to the development of serious complications. This study was done to elucidate whether a pulmonary contusion may induce programmed cell death. Sixty-four Wistar rats were evenly randomized to eight experimental groups: four sets were subjected to a standardized blast wave injury and sacrificed 6, 24, 48, and 72 h after the trauma; four groups served as controls for the same time points. Lung and liver samples were stained (H & E; TUNEL), and PMN infiltration was determined by myeloperoxidase (MPO) activity. Caspase 8 was analyzed by Western blot, and TNF-alpha plasma levels by ELISA. Postmortem examination revealed bilateral pulmonary contusion in trauma animals with higher (P < 0.05) numbers of apoptotic cells in lung but not in liver tissue as early as 6 h after the injury. This amount gradually increased and reached a maximum after 48 h: 6.8 +/- 1.1 apoptotic cells/hpf vs. 0.6 +/- 0.06 in controls. Chest trauma caused an increased expression of active caspase 8 in lung but not in liver tissue at 48 and 72 h. TNF-alpha plasma levels were not different. MPO activity in lung tissue of trauma animals increased (P < 0.05) after 6 h and peaked at 72 h. This study has provided the first evidence that apoptotic cell death in lung tissue is initiated following (experimental) pulmonary contusion. The exact mechanism remains, however, unclear and has to be elucidated further.
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Affiliation(s)
- Ulrich C Liener
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital of Ulm, D-89070 Ulm, Germany
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235
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Lomoschitz FM, Eisenhuber E, Linnau KF, Peloschek P, Schoder M, Bankier AA. Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms. Eur J Radiol 2003; 48:61-70. [PMID: 14511861 DOI: 10.1016/s0720-048x(03)00202-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In patients after chest trauma, imaging plays a key role for both, the primary diagnostic work-up, and the secondary assessment of potential treatment. Despite its well-known limitations, the anteroposterior chest radiograph remains the starting point of the imaging work-up. Adjunctive imaging with computed tomography, that recently is increasingly often performed on multidetector computed tomography units, adds essential information not readily available on the conventional radiograph. This allows better definition of trauma-associated thoracic injuries not only in acute traumatic aortic injury, but also in pulmonary, tracheobronchial, cardiac, diaphragmal, and thoracic skeletal injuries. This article reviews common radiographic findings in patients after chest trauma, shows typical imaging features resulting from thoracic injury, presents imaging algorithms, and recalls to the reader less common but clinically relevant entities encountered in patients after thoracic trauma.
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Affiliation(s)
- Fritz M Lomoschitz
- Department of Radiology, University of Vienna Medical School, AKH Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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236
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Ball CG, Hameed SM, Evans D, Kortbeek JB, Kirkpatrick AW. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 2003; 46:373-9. [PMID: 14577712 PMCID: PMC3211710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of clinical examination or plain radiography but is ultimately detected with thoracoabdominal computed tomography (CT). This situation is increasingly common in trauma care with the increased use of CT. The rate is approximately 5% in injured people presenting to hospital, with CT revealing at least twice as many pneumothoraces as suspected on plain radiography. Whereas pneumothorax is a common and treatable cause of mortality and morbidity, there is substantial disagreement regarding the appropriate treatment of OP. The greatest controversy is in patients in the critical care unit who require positive-pressure ventilation. There is little current evidence to direct the proper management of ventilated trauma patients with OP, and no studies have focussed specifically on these patients. Future randomized trials will need to consider the potential effects of OP on pulmonary mechanics and potential influences on the known risks of ventilator-induced lung injury associated with mechanical ventilation.
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Affiliation(s)
- Chad G Ball
- Department of Critical Care Medicine, Foothills Medical Centre, Calgary, Alta
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237
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Knöferl MW, Liener UC, Seitz DH, Perl M, Brückner UB, Kinzl L, Gebhard F. Cardiopulmonary, histological, and inflammatory alterations after lung contusion in a novel mouse model of blunt chest trauma. Shock 2003; 19:519-25. [PMID: 12785006 DOI: 10.1097/01.shk.0000070739.34700.f6] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Severe blunt chest trauma remains an important injury with high morbidity and mortality. However, the associated immunological alterations are poorly understood. Existing big animal models require large-scale settings, are often too expensive, and research products for immunological studies are limited. In this study we aimed to establish a new model of blunt, isolated and bilateral chest trauma in mice and to characterize its effects on physiological and inflammatory variables. Male C3H/HeN mice (n = 9-10/group) were anesthetized and a femoral artery was catheterized. The animals were subjected to trauma or sham procedure and monitored for 180 min. Blunt chest trauma was induced by a blast wave focused on the thorax. Trauma intensity was optimized by varying the exposure distance. Blood pressure, heart rate, respiratory rate, arterial blood gases and plasma cytokine levels were measured. Macroscopic and microscopic examinations were performed. In addition, outcome was evaluated in a 10-day survival study. Chest trauma caused a drop (P < 0.05) in blood pressure and heart rate, which partly recovered. Blood gases revealed hypoxemia and hypercarbia (P < 0.05) 180 min after trauma. There was marked damage to the lungs but none to abdominal organs. Histologically, the characteristic signs of a bilateral lung contusion with alveolar and intrabronchial hemorrhage were found. Plasma interleukin-6 and tumor necrosis factor alpha were considerably increased after 180 min. Blunt chest trauma resulted in an early mortality of 10% without subsequent death. On the basis of these findings, this novel mouse model of blunt chest trauma appears suitable for detailed studies on immunological effects of lung contusion.
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Affiliation(s)
- Markus W Knöferl
- Department of Trauma, Hand, and Reconstructive Surgery, University of Ulm, 89075 Ulm, Germany
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238
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Compère V, Genevois A, Le Corre A, Hellot MF, Bourguignon N, Vandelet P, Veber B, Dureuil B. Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma. Intensive Care Med 2003; 29:770-3. [PMID: 12682715 DOI: 10.1007/s00134-003-1682-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2002] [Accepted: 01/21/2003] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare the quality of interpretation of chest helicoidal computed tomography (HCT) by physicians with different levels of experience and medical specialty. DESIGN Prospective observational study. SETTING Trauma critical care unit at a French university hospital (US equivalent: level 1). PATIENTS HCT of 50 consecutive patients with blunt chest trauma were assessed by four groups of physicians [residents in anaesthesiology (n=5), residents in radiology (n=5), senior anaesthesiologists (n=5), and senior radiologists (n=5)]. Interpretation from each physician was compared with a grid obtained from an expert interpretation by a senior radiologist and a senior anaesthesiologist. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS No group of observers performed better than another in their interpretation of lung and parietal injuries on HCT. In contrast, senior radiologists were better than anaesthesiologists for the diagnosis of pneumomediastin. However, residents in radiology performed better than other physicians in detecting the presence of gastric and tracheal tubes. CONCLUSIONS Compared with anaesthesiologists, senior radiologists seem more expert in the diagnosis of HCT mediastinal injuries whereas residents in radiology were better at detecting resuscitation materials in thoracic trauma patients. This article reinforces the usefulness of the interpretation of the HCT by a senior radiologist in the case of blunt chest trauma. This also reinforces the usefulness of an aspect team of radiologists and anaesthesiologists in the case of trauma. The logical usefulness of a systematic interpretation of the images should be borne in mind.
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Affiliation(s)
- V Compère
- Department of Anaesthesiology and Critical Care, Charles Nicolle University Hospital, CHU-Hôpitaux de Rouen 1, rue de Germont, 76031 Rouen, France
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239
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Wang ND, Stevens MH, Doty DB, Hammond EH. Blunt chest trauma: an experimental model for heart and lung contusion. THE JOURNAL OF TRAUMA 2003; 54:744-8. [PMID: 12707538 DOI: 10.1097/01.ta.0000052362.40754.f2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blunt chest trauma is an important clinical problem leading to injury of the heart and lungs that may be fatal. Experimental models in large animals have been developed previously. This study was aimed at developing a small-animal (rat) model for the purpose of evaluating blunt chest trauma. METHODS Blunt trauma was delivered to the left side of the chest in rats by a captive bolt handgun. The gun was modified so that the amount of energy delivered to the chest wall could be adjusted. The injury energy varied from 1.7 to 6.8 J. Thirty-eight experiments in adult rats were performed. Electrocardiographic monitoring was performed continuously to determine cardiac rhythm. Gross and histologic examination of lungs and heart was performed at the time of death resulting from injury or euthanasia up to 13 days after injury. RESULTS Some form of cardiac arrhythmia accompanied blunt chest trauma in every case. Serious ventricular arrhythmia (tachycardia or fibrillation) was nearly always fatal (15 of 16 cases), but gross or histologic evidence of cardiac injury was present in only 31% of fatal cases. Lung injury (often bilateral) as shown by atelectasis and hemorrhage into the parenchyma or airway was found in 93% of the experiments when medium range energy force was applied. CONCLUSION This study has established a useful model for the study of blunt chest trauma in a small animal (rat). Blunt chest trauma is associated with cardiac arrhythmia, which may be fatal. Injury to the heart may not correlate with serious cardiac arrhythmia resulting in death, lending credence to the concept of cardiac concussion or commotio cordis. Lung contusion is always more obvious than morphologic injury to the heart.
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Affiliation(s)
- Nai-dong Wang
- Department of Surgery, LDS Hospital, Salt Lake City, Utah, USA
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240
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Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, Lemaire J, Martin M. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. THE JOURNAL OF TRAUMA 2003; 54:478-85. [PMID: 12634526 DOI: 10.1097/01.ta.0000037095.83469.4c] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.
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Affiliation(s)
- Eric Bergeron
- Choc-trauma Montérégie, Hôpital Charles-LeMoyne, Greenfield Park, Quebec, Canada.
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241
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Galanski M. Thoraxtrauma. Thorax 2003. [DOI: 10.1007/978-3-642-55830-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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242
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Tsuei BJ, Lyu PE. Chest radiography. Atlas Oral Maxillofac Surg Clin North Am 2002; 10:189-211. [PMID: 12518596 DOI: 10.1016/s1061-3315(02)00006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Betty J Tsuei
- Department of General Surgery, College of Medicine, University of Kentucky, 800 Rose Street, Room C-221, Lexington, KY 40536, USA.
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243
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Williams MJ. Blunt and Penetrating Trauma to the Thoracic Aorta. Semin Cardiothorac Vasc Anesth 2002. [DOI: 10.1177/108925320200600204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blunt and penetrating trauma to the thoracic aorta carries a highmortality at the scene of injury. The patients who arrive salvageable to the hospital need rapid diagnosis and treatment of the thoracicvessel injury. Blunt aortic injury is usually due to motor vehicle accidents. Penetrating injuries due to stab wounds or gunshot injury are regionally specific. The cardiac and pulmonary systems are associated with injury to the tho racic aorta in the majority of cases. The use of radiologic stud ies and recently, transesophageal echocardiography, aid in defining the site of injury and if there is accompanying cardiac injury. Large bore intravenous ines, multiple arterial lines, a pulmonary artery catheter to manage fluid replacement, and a double lumen endobronchial tube are needed for anesthetic management. The majority of patients die from exsanguina tion. There isneed while repairing the thoracic aorta, to main tain perfusion to the spinal cord with various methods in order to avoid perioperativeparaplegia. The injuries, diagnostic tests for locating sites of trauma, and perioperative management ap proaches associated with surgical repair are reviewed.
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Affiliation(s)
- Michael Jon Williams
- Department of Anesthesiology, Thomas aJefferson University, 111 South 11th Street, Suite 524 Main, Philadelphia, PA 19107
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Leone M, Portier F, Antonini F, Chaumoître K, Albanèse J, Martin C. [Strategies diagnosis of polytraumatized adult patients with coma]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:50-66. [PMID: 11878125 DOI: 10.1016/s0750-7658(01)00550-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the diagnostic strategy of management of multiple trauma patient during the first hours. DATA SOURCES Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years. DATA SELECTION The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected. DATA SYNTHESIS The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.
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Affiliation(s)
- M Leone
- Département d'anesthésie-réanimation et centre de traumatologie, CHU Nord, bd P-Dramard, 13915 Marseille, France
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Traumatologie II. Eur Surg 2002. [PMCID: PMC7101812 DOI: 10.1007/bf02950453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Exadaktylos AK, Sclabas G, Schmid SW, Schaller B, Zimmermann H. Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with "normal" chest radiograph? THE JOURNAL OF TRAUMA 2001; 51:1173-6. [PMID: 11740271 DOI: 10.1097/00005373-200112000-00025] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A major cause of morbidity and mortality after blunt chest trauma remains undetected injuries. This study evaluates the role of routine computed tomographic (CT) scan. METHODS We studied 93 consecutive patients from January 1999 to July 2000: 73 (76.3%) after motor vehicle crash with crash speed > 10 mph, and 22 (23.7%) after fall from height > 5 ft. Simultaneous with initial clinical evaluation, anteroposterior chest radiograph and helical chest CT scan were obtained for all patients. RESULTS Sixty-eight patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion. CONCLUSION Over 50% of patients with normal initial chest radiograph showed multiple injuries on the CT scan, among which were also two (8%) potentially fatal aortic lesions. We therefore recommend primary routine chest CT scan in all patients with major chest trauma.
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Affiliation(s)
- A K Exadaktylos
- Trauma and Emergency Unit, Inselspital, University of Berne, Inselspital, Berne, Switzerland.
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Gallego P, Oliver JM, González A, Domínguez FJ, Sanchez-Recalde A, Mesa JM. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr 2001; 14:813-20. [PMID: 11490330 DOI: 10.1067/mje.2001.113366] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. We discuss a series of 11 patients with pathologically confirmed left atrial dissection who had been diagnosed previously by transesophageal echocardiography. Predisposing factors and surgical or pathologic findings were reviewed to identify the pathogenic mechanism and to explain the clinical course, hemodynamic disorder, and echocardiographic features. Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, and blunt chest trauma also could be related to its development. Transesophageal echocardiography identified a mobile intimal flap of the atrial wall that was creating a false chamber and allowed accurate diagnosis of prosthetic mitral valve function, endocarditis complications, and a left ventricular pseudoaneurysm after acute myocardial infarction. Color flow Doppler was particularly useful in identifying complications: communication between the false chamber and true left atria, permitting mitral regurgitation through the periannular route; development of atrial shunts; and severe tricuspid regurgitation caused by disruption of the anterior papillary muscle.
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Affiliation(s)
- P Gallego
- Departments of Cardiology and Cardiovascular Surgery, La Paz General Hospital, Autonoma University, Madrid, Spain.
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Chen JD, Shanmuganathan K, Mirvis SE, Killeen KL, Dutton RP. Using CT to diagnose tracheal rupture. AJR Am J Roentgenol 2001; 176:1273-80. [PMID: 11312194 DOI: 10.2214/ajr.176.5.1761273] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A retrospective study was performed to assess CT sensitivity for diagnosing tracheal rupture. Intubated cadaver tracheas were examined to assess endotracheal tube balloon overdistention and deformity and to evaluate the relationship of balloon pressures to tracheal injury. MATERIALS AND METHODS Neck or chest CT scans of 14 patients with tracheal rupture and 41 control trauma patients with pneumomediastinum but without tracheal injury were reviewed and compared to assess the presence and location of extrapulmonary air, whether direct visualization of tracheal wall disruption was possible, the size and shape of endotracheal tube balloon, signs of transtracheal balloon herniation in intubated patients, and the location of the extratracheal endotracheal tube. Intact and experimentally injured cadaver tracheas were used to evaluate tube balloon pressure and configuration. RESULTS All 14 patients with tracheal rupture had deep cervical air and pneumomediastinum. Overdistention of the tube balloon occurred in 71% (5/7) of the intubated patients, and balloon herniation occurred in 29% (2/7). Direct tracheal injury was seen in 71% (10/14) of the patients as a wall defect (n = 8) or deformity (n = 2). Overall, CT was 85% sensitive for detecting tracheal injury. Patients with tracheal injury had a significantly lower incidence of pneumothorax (p = 0.01) than did the control group. The CT appearance of balloon herniation through defects in the cadaver tracheas closely mimicked those of patients with tracheal injury. The amount of balloon pressure required to rupture the intubated trachea was extremely high and rupture was difficult to obtain. CONCLUSION CT can reveal tracheal injury and can be used to select trauma patients with pneumomediastinum for bronchoscopy, leading to early confirmation and treatment.
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Affiliation(s)
- J D Chen
- Department of Radiology, Veterans General Hospital, Taipei and National Yang-Ming Medical School, Taipei, Taiwan
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López Espadas F, Zabalo M, Encinas M, Díaz Regañón G, González Fernández C, Pagola M. Rotura bronquial en traumatismo torácico cerrado. Arch Bronconeumol 2000. [DOI: 10.1016/s0300-2896(15)30088-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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