[Chest injury. Part I: Significance--symptoms--diagnostic procedures]

[Imaging of blunt chest trauma]

CLINICAL/METHODOLOGICAL ISSUE

Blunt chest trauma is associated with high morbidity and mortality. Consequently, all patients should be evaluated radiologically after blunt chest trauma to allow timely and appropriate treatment.

STANDARD RADIOLOGICAL METHODS

Conventional chest radiographs and computed tomography (CT) are proven modalities with which to evaluate patients after blunt chest trauma.

METHODOLOGICAL INNOVATIONS

Over the last several years extended focused assessment with sonography for trauma (eFAST) has gained increasing importance for the initial assessment of seriously injured patients.

PRACTICAL RECOMMENDATIONS

In the acute phase of severely injured patients eFAST examinations are helpful to exclude pneumothorax, hemothorax and hemopericardium. Chest radiographs may also be used to diagnose a pneumothorax or hemothorax; however, the sensitivity is limited and CT is the diagnostic modality of choice to evaluate severely injured patients.

Patients with thoracic trauma and concomitant spinal cord injury have a markedly decreased mortality rate compared to patients without spinal cord injury

INTRODUCTION

The present study was performed to compare the clinical outcome, with special focus on the mortality rate of thoracic injuries, in patients with and without spinal cord injury.

MATERIALS AND METHODS

Patients who were treated for thoracic trauma at our institution between January 1998 and December 2007 were included in this retrospective cohort study. Patients were divided into two groups according to whether they had suffered a concomitant spinal cord injury (SCI) (N = 54) or not (N = 61). Survival analysis was performed using the Kaplan-Meier function and the Cox proportional hazards model. Age, sex, injury severity score (ISS), Charlson comorbidity index (CCI), and infection with pneumonia were included as covariates in the final model.

RESULTS

Patients with SCI have a 65 % reduction in the chance of dying compared to patients without SCI following thoracic trauma (HR = 0.35; 95%CI = 0.13-0.96; p = 0.041). Sex (HR = 0.67; 95 % CI: 0.26-1.71, P = 0.141), ISS > =25 (HR = 2.08 95 % CI: 0.58-7.49, P = 2.63) and a Charlson Comorbidity Index of 2 (HR = 1.82; 95 % CI: 0.58-7.22, P = 0.393) had no effect in the risk of dying. However, patients older than 60 years had four times the chance of dying than patients younger than 30 years (HR = 4.39; 95 % CI: 1.02-19, P = 0.048). Patients with pneumonia had a nonsignificant twofold increase in the risk of dying (HR = 2.28; 95 % CI: 0.97-5.34, P = 0.059).

CONCLUSIONS

Our results demonstrate that patients with thoracic trauma and concomitant SCI had markedly decreased mortality compared to patients without SCI, even after adjusting for age, sex, injury severity, comorbidities and pneumonia infection.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

Background

The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS.

Material and methods

Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes.

Results

A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105).

Conclusion

The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Use of extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threatening complications in trauma patients. Despite the implantation of a veno-venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO(2)  > 90%) is not always achieved. The additive use of high-frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life-threatening hypoxaemia and multi-organ failure. We report on a 26-year-old female (Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz-Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz-Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen (FiO(2) ) was significantly reduced. The pelvic fracture was treated non-operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days.

[Bilateral injuries of the internal mammary artery following blunt thoracic trauma]

Injuries of the internal mammary artery after blunt thoracic trauma are rare but potentially fatal. A specific characteristic of these injuries is that they can become symptomatic even after a delay of several weeks. This article reports on the diagnosis and treatment of a 41-year-old motorcycle rider who suffered bilateral injuries of the internal mammary artery after a motorcycle accident without any additional bony lesions.

[Herniation of the middle lobe of the right lung due to a coarsely dislocated sternum fracture]

In cases of multiple trauma in patients with an injury severity score (ISS) > or =16 chest injuries, abbreviated injury scale (AIS) > or =3, are also sustained in 57.2% of all patients. Life-threatening complications may occur with lung contusions and rib fractures also in combination with hemothorax/pneumothorax being the most common diagnoses. In addition the lungs can also be functionally impaired by ruptures of the great thoracic vessels or in isolated cases by herniation of lung tissue following tears in the wall of the thorax. A case of multiple trauma in a 44-year-old male (ISS 29) with blunt thoracic trauma resulting in herniation of the middle lobe of the right lung into the subcutaneous tissue due to a coarsely dislocated fracture of the sternum is reported. This still ventilated lung tissue was surgically resituated 4 weeks after the event and the sternum fracture was simultaneously stabilized by plate osteosynthesis. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential. Therefore, standard diagnostic procedures combined with multislice computed tomography during the first examination and reassessment should be included to avoid missed injuries.

[Trauma care management]

Optimal outcome in the treatment of multiple trauma patients requires an initial management fulfilling a high standard of quality assurance. A prerequisite is the availability of adequate resources at all times with respect to personnel, technical equipment, and emergency room design. The aim is-based on standardized and prioritized clinical pathways and algorithms-to identify and treat not only life-threatening and debilitating but all other injuries in a timely fashion. Diagnostic and therapeutic measures to manage airway, breathing, and circulatory problems (including transfusion and surgery for bleeding control) have priority, even over the operative treatment of severe head injuries. With respect to severe intra-abdominal and retroperitoneal injuries, the concept of damage control surgery has reached world wide acceptance. However, many parenchymal lesions of intra-abdominal organs can be managed nonoperatively. Similarly, damage control orthopedics for the initial management of major fractures with initial temporary and minimally invasive fracture stabilization followed by definitive osteosynthesis as soon as the patient has stable organ functions is gaining more acceptance. Maintainance of and improvement in the quality of care requires standardized documentation, regular analysis, and feedback in an internal quality management process as well as participation in an external quality program such as the Trauma Registry of the German Society for Accident Surgery.