Posttraumatic empyema. Risk factor analysis

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

BACKGROUND

Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements.

RESULTS

A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection.

CONCLUSION

This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Risk factors for posttraumatic empyema in diaphragmatic injuries

Background

Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.

Methods

This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.

Results

We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22–35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18–44) and 17 (10–27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77–23. 43), and visible contamination (OR 5.13, 95% IC 1.26–20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.

Conclusion

The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

Optimal Initial Positioning of Chest Tubes to Prevent Retained Hemothorax Using a Novel Steerable Chest Tube With Extendable Infusion Cannula

INTRODUCTION

With blunt and penetrating trauma to the chest, warfighters and civilians frequently suffer from punctured lung (pneumothorax) and/or bleeding into the pleural space (hemothorax). Optimal management of this condition requires the rapid placement of a chest tube to evacuate as much of the blood and air as possible. Incomplete drainage of blood leading to retained hemothorax may be the result of the final tube tip position not being in contact with the blood collections. To address this problem, we sought to develop a "steerable" chest tube that could be accurately placed or repositioned into a specific desired position in the pleural space to assure optimal drainage. An integrated infusion cannula was added for the instillation of anticoagulants to maintain tube patency, thrombolytics for clot lysis, and analgesics for pain control if required.

MATERIALS AND METHODS

A triple-lumen tube was designed to provide a channel for a pull-wire which was wound around an axle integrated into a small proximal handle and controlled by a ratcheted thumbwheel. Tension on the wire creates an arc on the tube that allows for positioning. In vitro testing focused on the relationship between the tension on the pull-wire and the resultant arc. Two adult cadavers and two anesthetized pigs were used to study the feasibility of accurate tube placement. After a brief training session, providers were asked to place tubes inferiorly along the diaphragm where blood was anticipated to accumulate or at the apex of the lung for pneumothorax. Success was determined with fluoroscopic images and was judged as a tube tip lying in the targeted position.

RESULTS

The design was prototyped with an extruded polyvinyl chloride multilumen tube and a 3D printed tensioning handle. In vitro studies showed that one turn of the thumbwheel created 70° to 90° of arc of the tube. Cadaver and animal studies showed consistent success in the desired placement of the tube at or near the lateral diaphragm or in the apex. Attempts were also successful by surgical residents with minimal training.

CONCLUSIONS

Initial preliminary studies on a novel steerable chest tube have demonstrated the ability to appropriately position the tube in a desired location. The addition of an extendable cannula will allow for safe clot lysis or maintained tube patency. Additional studies are planned to confirm the benefit of this device in preventing retained hemothorax.

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial

BACKGROUND

The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH.

METHODS

We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX.

RESULTS

A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up.

CONCLUSION

Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study

Background

Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement.

Methods

The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively.

Results

TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53).

Conclusion

There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship.

Level of evidence

II Prospective comparative study

Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms

Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema

BACKGROUND

Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF).

METHODS

Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests.

RESULTS

One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002).

CONCLUSIONS

Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.

Associated factors to empyema in post-traumatic hemotorax

ABSTRACTObjective:to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax.Methods:prospective observational study. Data were collected in patients undergoing PD during emergency duty. Variables analyzed were age, sex, mechanism of injury, side of the chest injury, intrathoracic complications of RH, laparotomy, specific injuries, rib fractures, trauma scores, days to diagnosis, diagnostic method of RH, primary indication of PD, initial volume drained, length of the first tube removal, surgical procedure. Cumulative incidence of empyema, pneumonia and pulmonary contusion and the proportion of patients with empyema or without empyema in each category of each variable analyzed were obtained.Results: the cumulative incidence of PD among trauma patients was 1.83% and the RH among those with PD was 10.63%. There were 20 cases of empyema (32.8%). Most were male in the age from 20 to 29, victims of injury by firearm on the left side of the thorax. The incidence of empyema in patients with injury by firearms was lower compared to those with stab wound or blunt trauma; higher among those with drained volume between 300 and 599 ml. The median hospital lenght of stay was higher among those with empyema.Conclusion:the incidence of PD was 1.83% and RH was 10.63%, these results are consistent with the low severity of the patients involved in this study and consistent with the literature. The incidence of empyema proved to be negatively associated with the occurrence of injury by firearms and positively associated with a drained volume between 300 and 599 ml, compared with lower or higher volumes.

Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients

INTRODUCTION

Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome.

METHODS

Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up.

RESULTS

One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema.

CONCLUSIONS

Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study

INTRODUCTION

Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH.

METHODS

We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived.

RESULTS

328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH.

CONCLUSIONS

To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.

Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice.

METHODS

A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence.

RESULTS

Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis?

CONCLUSION

Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Initial Suction Evacuation of Traumatic Hemothoraces: A Novel Approach to Decreasing Chest Tube Duration and Complications

Between 2 and 4.4 per cent of all patients with trauma chest tubes develop retained hemothoraces. Retained hemothoraces prolong chest tube duration and hospital length of stay, and increase infectious complications like empyema. Early surgical drainage of retained hemothoraces has been shown to decrease complications and reduce hospital length of stay. However, the high resource and expertise requirement may limit the widespread applicability of surgical drainage. We present the results of a relatively simple and novel intervention for traumatic hemothoraces undertaken by our faculty to shorten chest tube duration and prevent empyema formation. At our Level I trauma center, 10 trauma patients underwent initial suction evacuation of their traumatic hemothoraces using a sterile suction catheter before chest tube placement. Compared with propensity matched controls, patients that underwent initial suction evacuation experienced significantly shorter chest tube duration (4.2 ± 1.9 vs 5.8 ± 2.3 days, P = 0.04). Also, in this population, there was an 8.2 per cent decrease in the number of patients that developed empyema or required additional drainage. Our study suggests that initial suction evacuation of traumatic hemothoraces is an effective and relatively easy intervention that reduces the duration of chest tube therapy, empyema formation, and the need for additional surgical intervention.

Co-existence of posttraumatic empyema thoracis and lung abscess in a child after blunt chest trauma: a case report

Posttraumatic empyema is a rare complication of trauma with an incidence of 1.6-2.4% in trauma patients. However, it is rarely reported in children. We report the case of a 15-year-old boy who was involved in a traffic accident and diagnosed with a pulmonary contusion at a local hospital. Fourteen days after the accident, posttraumatic empyema thoracis and lung abscess developed with clinical presentations of fever, productive cough and right chest pain. He was successfully treated with computed tomography-guided catheter drainage and intravenous cefotaxime. We emphasize that posttraumatic empyema thoracis and lung abscess are very rare in children, and careful follow-up for posttraumatic lung contusion is essential. Image-guided catheter drainage can be an adjunctive tool for treating selected patients, although most complicated cases of posttraumatic empyema thoracis require decortication therapy.

Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury

BACKGROUND

Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies.

OBJECTIVE

To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema.

METHODS

A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score.

RESULTS

A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4+/-26) versus those who did not (22.6+/-13; P=0.03).

CONCLUSIONS

The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.

Common complications following thoracic trauma: their prevention and treatment

Although there are a wide range of complications following thoracic trauma, respiratory failure, pneumonia, and pleural sepsis are the most common potentially preventable problems. Respiratory failure and pneumonia are directly related to the severity of the injury and the age and condition of the patient. A program aimed at aggressive pain control, mobilization, and pulmonary care can reduce the risk of respiratory failure, pneumonia, and death in these patients. Pleural sepsis develops in the face of a retained hemothorax, which becomes contaminated with bacteria. The most common source for this contamination is not pneumonia, but external contamination from the wound itself or at the time of placement of the tube thoracostomy. Measures that reduce the volume of retained pleural blood and reduce or eliminate any bacterial contamination are likely to reduce the incidence of pleural sepsis. The authors review these complications and describe a plan to reduce these complications.

Prophylactic Antibiotics in Chest Trauma: A Meta-analysis of High-quality Studies

BACKGROUND

Use of antibiotics in patients with isolated chest trauma is controversial. Available studies offer contradictory results because of small sample sizes. However, information provided by recent randomized controlled trials (RCT) included in a systematic review and meta-analysis could help solve the controversy. We performed a systematic review using high-quality information related to the use of antibiotics in patients with a chest tube.

METHODS

We developed a systematic review to evaluate the effectiveness of prophylactic antibiotics in chest-trauma patients. Studies included were class I RCT comparing prophylactic antibiotics versus placebo in patients with isolated chest trauma. Main outcomes were posttraumatic empyema and pneumonia.

RESULTS

Five Class I studies were selected. There were statistically significant differences regarding the frequency of posttraumatic empyema (RR 0.19) and pneumonia (RR 0.44) in favor of the use of prophylactic antibiotics when compared with placebo.

CONCLUSIONS

The use of prophylactic antibiotics in patients with chest trauma decreases the incidence of posttraumatic empyema and pneumonia.

The Spectrum of Pleural Effusions After Coronary Artery Bypass Grafting Surgery

Pleural effusions are common after coronary artery bypass grafting (CABG) surgery and can be categorized by time intervals: perioperative (within the first week), early (within 1 month), late (2-12 months), or persistent (after 6 months). The perioperative effusions are usually attributable to diaphragm dysfunction or internal mammary artery harvesting and are typically self-limited. Early effusions are usually attributable to postcardiac injury syndrome and may require corticosteroid treatment. Although late effusions can have multiple causes, persistent effusions are attributable to trapped lung and often require decortication. Diagnostic thoracentesis should be performed for patients with large symptomatic pleural effusions or fever after CABG surgery. The range of management includes observation, therapeutic thoracentesis, corticosteroids, or decortication depending on the cause and course of the effusion.

Prehospital Chest Tube Thoracostomy: Effective Treatment or Additional Trauma?

BACKGROUND

The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT.

METHODS

Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections.

RESULTS

Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant).

CONCLUSION

The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT.

Pathogenesis of posttraumatic empyema: the impact of pneumonia on pleural space infections

BACKGROUND

Thoracic empyema may result either from primary pneumonic sources or intraabdominal sources of infection that seed the pleural space secondarily. In patients with thoracostomy tubes, empyema may result when blood in the pleural space becomes contaminated during tube insertion. To elucidate the cause of posttraumatic empyema, preoperative bronchoalveolar lavage (BAL)/sputum cultures obtained from patients with posttraumatic empyema were compared with cultures obtained at the time of decortication.

MATERIALS AND METHODS

A retrospective study was conducted of trauma patients who developed empyema and underwent either video-assisted thoracoscopy or thoracotomy with decortication following blunt or penetrating trauma. At our level I trauma center, we studied all empyema cases diagnosed from November, 1998 to July, 2001. Data collection included patient demographics, injuries sustained, preoperative BAL/sputum cultures, and culture data obtained at the time of decortication. All BAL/sputum cultures were performed no more than 5 days prior to decortication.

RESULTS

Thirty-seven patients (26 blunt/11 penetrating) were identified. No patients had concurrent intra-abdominal sources of infection. All patients had at least one chest tube placed prior to decortication. Preoperative respiratory cultures (BAL/sputum) were obtained in 34 patients. The most common organisms isolated were Staphylococcus aureus in six patients (18%) and Hemophilus influenzae in six patients (18%). Intraoperative cultures were obtained in all 37 patients, with the most common organism being S. aureus isolated in 22 patients (60%). Interestingly, a correlation between preoperative BAL/sputum and intraoperative cultures was found in only seven of the 34 patients (21%) who had concomitant respiratory and pleural cultures. Cultures positive for S. aureus were isolated from five patients, Streptococcus pneumoniae from one patient, and Pseudomonas aeruginosa from one patient.

CONCLUSION

Little correlation existed between preoperative BAL/sputum cultures and intraoperative cultures in this series of patients with posttraumatic empyema. This suggests that the causation is most often not a parapneumonic process. Furthermore, since S. aureus was the most common organism recovered from empyema, the source was more likely from inoculation of the pleural space by the injury itself or by tube thoracostomy.

Empyema and Restrictive Pleural Processes after Blunt Trauma: An Under-Recognized Cause of Respiratory Failure

Respiratory failure is a common complication among patients sustaining major blunt trauma. This is usually due to the underlying pulmonary injury, pneumonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of their respiratory failure. Our objective was to assess the frequency of empyema and restrictive pleural processes after blunt trauma and their contribution to respiratory failure. We retrospectively reviewed all blunt trauma patients over a 5-year period who required a thoracotomy and decortication for empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, loculated hemothorax/effusion in 23 patients, whereas 5 had an associated pneumonia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patients showed previously unrecognized fluid collections, air-fluid levels, or gas bubbles. Neither thoracentesis nor placement of additional chest tubes was helpful. Positive cultures were uncommon. Ventilator dependence was present preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under-recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.