Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience

Insights into epidemiological trends of severe chest injuries: an analysis of age, period, and cohort from 1990 to 2019 using the Global Burden of Disease study 2019

BACKGROUND

This study assessed the global trends and burden of severe chest injury, including rib fractures, lung contusions, and heart injuries from 1990 to 2019. Herein, we predicted the burden patterns and temporal trends of severe chest injuries to provide epidemiological evidence globally and in China.

METHODS

In our analysis, the age-standardized incidence rate (ASIR), prevalence rate (ASPR), and years lived with disability rate (ASYR) of severe chest injury were analyzed by gender, age, sociodemographic index, and geographical region between 1990 and 2019 using data from the Global Burden of Disease study 2019. Trends were depicted by calculating the estimated annual percentage changes (EAPCs). The impact of age, period, and cohort factors was assessed using an Age-Period-Cohort model. Autoregressive integrated moving average (ARIMA) model was employed to predict severe chest injury trends from 2020 to 2050.

RESULTS

In 2019, the global number of severe chest injury cases reached 7.95 million, with the highest incidence rate observed in Central Europe (209.61). Afghanistan had the highest ASIRs at 277.52, while North Korea had the lowest ASIRs at 41.02. From 1990 to 2019, the Syrian Arab Republic saw significant increases in ASIR, ASPR, and ASYR, with EAPCs of 10.4%, 9.31%, and 10.3%, respectively. Burundi experienced a decrease in ASIR with an EAPC of - 6.85% (95% confidence interval [CI] - 11.11, - 2.37), while Liberia's ASPR and ASYR declined with EAPCs of - 3.22% (95% CI - 4.73, - 1.69) and - 5.67% (95% CI - 8.00, - 3.28), respectively. Falls and road injuries remained the most common causes. The relative risk of severe chest injury by age, period, and cohort demonstrated a complex effect globally and in China. The ARIMA model forecasted a steady increase in global numbers from 2020 to 2050, while in China, it forecasted an increase in incidence, a decrease in ASIR and ASYR, and an increase in ASPR.

CONCLUSIONS

This study provides a groundbreaking analysis of global severe chest injury, shedding light on its measures and impact. These findings highlight the need for timely, specialized care and addressing regional disparities to mitigate the severe chest injury burden.

The Harsh Reality: Outcomes of Patients With Operatively Managed Lung Injuries

INTRODUCTION

Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale.

METHODS

We performed a retrospective analysis of the ACS-TQIP 2017-2020. We included all adult trauma patients with lung injuries that underwent operative management. Patients were stratified based on type of surgery into 3 groups (wedge resection, lobectomy, pneumonectomy). The outcome was mortality. Multivariable logistic regression analysis was performed to identify the independent predictors of mortality.

RESULTS

We identified a total of 170,377 patients with lung injuries, out of which 2159 (1.3%) patients underwent operative management (Wedge resection [61%], Lobectomy [31%], Pneumonectomy [8%]). Among operatively managed patients, the mean (SD) age was 37 (16) years, and 86% were male. Overall, 65% sustained penetrating injuries, with a median [IQR] ISS of 25 [16 - 33], and median [IQR] lung injury AIS severity of 4 [3 - 4]. About 7% of the patients suffered hilar injuries. The mean (SD) SBP on arrival was 108 (43) and the median [IQR] time to surgery was 177 [52 - 5351] minutes. The median hospital LOS was 10 [1 - 19] days, and overall mortality rate was 30%. On univariate analysis, patients undergoing pneumonectomy had the highest mortality (54%), followed by lobectomy (33%), and wedge resection (25%). On multivariable regression analysis, hilar injuries (aOR 1.9, 95%CI = 1.06 - 2.80, P = 0.029), increasing age (aOR 1.02, 95%CI = 1.01 - 1.03, P = 0.001), concomitant head (aOR 1.34, 95%CI = 1.22 - 1.47, P < 0.001) and abdominal injuries (aOR 1.42, 95%CI = 1.31 - 1.54, P < 0.001) were independent predictors of mortality.

CONCLUSIONS

Nearly 1 in 3 patients with lung injuries who were managed operatively did not survive their index admission. These findings highlight that operatively managed lung injuries still carry a high risk of mortality and should be reserved for selected patients. The decision for surgery in patients with concomitant head or abdominal injuries must be taken on a case-to-case basis.

Prognostic Factors and Clinical Outcomes of Surgical Treatment of Major Thoracic Trauma

BACKGROUND

Major thoracic trauma represents a life-threatening condition, requiring a prompt multidisciplinary approach and appropriate pathways for effective recovery. While acute morbidity and mortality are well-known outcomes in thoracic-traumatized patients, long-term quality of life in patients surviving surgical treatment has not been widely investigated before.

METHODS

Between November 2016 and November 2023, thirty-two consecutive patients were operated on because of thoracic trauma. Age, sex, comorbidities, location and extent of thoracic trauma, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), Organ Injury Scale (OIS), intra and extrathoracic organ involvement, mechanism of injury, type of surgical procedure, postoperative complications, ICU and total length of stay, immediate clinical outcomes and long-term quality of life-by using the EQ-5D-3L scale and Numeric Rate Pain Score (NPRS)-were collected for each patient Results: Results indicated no significant difference in EQOL.5D3L among patients with thoracic trauma based on AIS (p = 0.55), but a significant difference was observed in relation to ISS (p = 0.000011).

CONCLUSIONS

ISS is correlated with the EQOL.5D3L questionnaire on long-term quality of life, representing the best prognostic factor-in terms of long-term quality of life-in patients surviving major thoracic trauma surgical treatment.

Ventilation Management in a Patient with Ventilation-Perfusion Mismatch in the Early Phase of Lung Injury and during the Recovery

Chest trauma is one of the most serious and difficult injuries, with various complications that can lead to ventilation-perfusion (V/Q) mismatch and systemic hypoxia. We are presenting a case of a 53-year-old male with no chronic therapy who was admitted to the Intensive Care Unit due to severe respiratory failure after chest trauma. He developed a right-sided pneumothorax, and then a thoracic drain was placed. On admission, the patient was hemodynamically unstable and tachypneic. He was intubated and mechanically ventilated, febrile (38.9 °C) and unconscious. A lung CT showed massive non-ventilated areas, predominantly in the right lung, guiding repeated therapeutic and diagnostic bronchoalveolar lavages. He was ventilated with PEEP of 10 cmH2O with a FiO2 of 0.6-0.8. Empirical broad-spectrum antimicrobial therapy was immediately initiated. Both high FiO2 and moderate PEEP were maintained and adjusted according to the current blood gas values and oxygen saturation. He was weaned from mechanical ventilation, and non-invasive oxygenation was continued. After Stenotrophomonas maltophilia was identified and treated with sulfamethoxazole/trimethoprim, a regression of lung infiltrates was observed. In conclusion, both ventilatory and antibiotic therapy were needed to improve the oxygenation and outcome of the patient with S. maltophilia pneumonia and V/Q mismatch.

Eita Y, Ahmed Aglan MA, Esmaiel MSA, Abdelshafy Ibrahim Farag G, Abdmokhles Abdelmottaleb N, Elkahely MA, A Mansour M. A Prospective Study of Chest Trauma Scoring System as A Morbidity and Mortality Predictor in Patients with Blunt Chest Trauma

Background

Predicting the outcome of blunt chest trauma by scoring systems is of utmost value. We aimed to assess the role of the chest trauma scoring system (CTS) in predicting blunt chest trauma outcomes among Egyptians.

Methods

A prospective observational study included 45 patients admitted to the cardiothoracic emergency unit of Al-Azhar University hospitals. We documented their demographic data, history, cause and mode of trauma, vital parameters, and necessary investigations (e.g., chest X-ray and Computed Tomography) when the patient was admitted to the cardiothoracic department. All patients were assessed using the chest trauma scale (CTS) and followed up till death or discharge.

Results

The patient's age ranged between 18 to 76 years (mean 42.67 years). Eighty percent were males, and 48% needed mechanical ventilation (MV). The period of MV was ranged from 1 to 5 days (mean 2.81 days). Twenty-two patients had pneumonia. Eight patients died with a chest trauma scale ranging from 2 to 12 with a median of 6. About 87 percent of patients had unilateral lesions, and 5 had criminal causes. Road traffic accidents were the most typical cause of trauma (60%). There was a significant relation between mortality among the studied patients and each MV, length of ICU duration, chest trauma scale, laterality of trauma, and associated injuries. There was a statistically significant relation between the chest trauma scale and the need for MV, the timing of MV, the presence of pneumonia, and mortality.

Conclusion

CTS ≥ 6.5 can predict mortality with 100.0% sensitivity, specificity of 62.2%, and accuracy of 68.9%. However, a score of ≥ 5.5 can predict the development of pneumonia with a sensitivity of 81.8%, specificity of 78.3%, and accuracy of 80%.

The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU

BACKGROUND

Up to 25% of trauma deaths are related to thoracic injuries.

OBJECTIVE

The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window.

DESIGN

Retrospective observational analysis.

SETTING

TraumaRegister DGU.

PATIENTS

Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related.

MAIN OUTCOME MEASURES

Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death.

RESULTS

Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n  = 24 332) mortality was 5.9% ( n  = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission.

CONCLUSION

About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths.

TRIAL REGISTRATION

The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.

A Retrospective Two-Year Review of the Outcomes of Surgical Rib Fixation Following Chest Wall Injury by the Multidisciplinary Chest Wall Injury Group in a Major Trauma Centre and the Change in Outcomes as the Service Has Developed

Aims All English major trauma centres (MTCs) offer rib fixation, which the National Institute for Health and Care Excellence (NICE) guidance indicates in patients with multiple rib fractures or a flail segment; however, the data does not identify the appropriate patients. Our aims were to establish improvements in outcomes following rib fixation at our trust and then determine if the rib fixation service has improved. Methods We performed a matched cohort study whereby 32 patients who underwent rib fixation were independently matched with conservatively managed patients. We then performed a retrospective re-audit to compare outcomes with the matched cohort study. The outcomes analysed were mortality, critical care length of stay (LOS) and total hospital LOS. Results Our initial study revealed a 33.4% reduction in mortality in patients over 55 years. There was also a reduction in average total hospital LOS by 4.5 days in patients under 55 years when comparing rib fixation to conservative management. The results also revealed an average of 4.1 days from admission to operation, 12.7 days of critical care LOS and 29.1 days of total hospital LOS. The re-audit showed improvements in all outcomes. Time from admission to fixation was reduced to 2.1 days, critical care LOS was reduced to 7.5 days and total hospital LOS was reduced to 20.7 days. Conclusions Reduced mortality and LOS reinforce evidence that rib fixation improves outcomes. The re-audit shows that patients are identified for fixation sooner, which is important as the evidence has not identified optimal time for fixation. LOS further decreased in our re-audit, which indicates that earlier fixation results in patients avoiding the sequelae of rib fractures.

A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center

Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma

INTRODUCTION

Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT.

METHODS

We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality.

RESULTS

A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02).

CONCLUSIONS

The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality

BACKGROUND

Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

METHODS

Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

RESULTS

A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

CONCLUSION

Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Flail chest injury-changing management and outcomes

PURPOSE

The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes.

METHODS

A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included.

RESULTS

Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007).

CONCLUSION

Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort.

Chest Trauma Management in Low- and Middle-Income Countries

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

Mast Cells Drive Systemic Inflammation and Compromised Bone Repair After Trauma

There is evidence that mast cells contribute to inflammation induced by hemorrhagic shock, severe tissue injury or sepsis. Mast cells are highly responsive to alarm signals generated after trauma, and release many inflammatory mediators including interleukin-6, a key mediator of posttraumatic inflammation. An overwhelming posttraumatic inflammation causes compromised bone healing; however, the underlying cellular and molecular mechanisms are poorly understood. Recently, we found that mast cells trigger local and systemic inflammation after isolated fracture leading to uneventful bone repair. Here, we investigated whether mast cells critically contribute to trauma-induced compromised bone healing. Male Mcpt5-Cre⁺ R-DTA mice, which lack connective tissue type mast cells, and their mast cell-competent Cre^- littermates underwent a femur fracture with/without thoracic trauma. Posttraumatic systemic and local inflammation and bone repair were assessed 3 h and 21 d post injury. Both, the systemic and pulmonary inflammation was significantly increased in mast cell-competent mice upon combined trauma compared to isolated fracture. In mast cell-deficient mice, the increase of inflammatory mediators in the circulation induced by the severe trauma was abolished. In the bronchoalveolar lavage fluid, the trauma-induced increase of inflammatory cytokines was not reduced, but the neutrophil invasion into the lungs was significantly diminished in the absence of mast cells. Locally in the fracture hematoma, mast cell-competent mice displayed reduced inflammatory mediator concentrations after combined trauma compared to isolated fracture, which was abolished in mast cell-deficient mice. Notably, while combined trauma resulted in compromised bone repair in mast cell-competent mice, indicated by significantly reduced bone and increased cartilage fracture callus contents, this was abolished in Mcpt5-Cre⁺ R-DTA mice. Therefore, mast cells contribute to trauma-induced compromised bone repair and could be a potential target for new treatment options to improve fracture healing in multiply injured patients.

Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study

Background

Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries.

Methods

We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome.

Results

A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25–58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70–79 years age group, while this was observed in the 20–29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]).

Conclusion

Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.

Costal cartilage fracture: A commonly missed thoracic injury in trauma patients

In this report, we describe a case of a 43-year-old male who sustained a displaced mid chondral costal cartilage fracture along with multiple ipsilateral rib fractures following a jet ski collision. Costal cartilage fractures (CC) are commonly missed on imaging evaluation, and accordingly underreported in the literature. High-energy blunt chest trauma represents the most common mechanism for CC injuries. Computed Tomography (CT) is the modality of choice to diagnose CC fractures along with the associated cardiopulmonary and abdominal injuries in polytrauma patients. There is currently no consensus with respect to the management of CC fractures. Further research is required to explore the long-term impact of CC fractures on thoracic cage stability.

Influence of Severe Thoracic Trauma on Choosing the Correct Surgical Strategy in Patients with Polytrauma from Kosovo

Background

Severe thoracic trauma (TT) has a significant impact on the selection of treatment strategy in patients with polytrauma. Our aim was to assess the impact of severe TT on choosing the optimal surgical procedure to decrease mortality.

Material/Methods

Overall, 66 patients with polytrauma and significant TT were analyzed. Demographic data, trauma history, admittance imaging, injury details, injury severity scores, conservative treatment, surgical treatment, days of hospital stay, and mortality data were gathered. Frequencies of thoracic surgical procedures and other treatments were collected and compared with those in the literature.

Results

All patients had Abbreviated Injury Scale (AIS) scores of thorax >3. Injuries to extremities and/or the osseous pelvis accounted for 50% of injuries; 47.0% included the head and/or neck; 45.5% were external injuries; and 27.3% were abdominal injuries or included pelvic organs and/or lumbar spine. Mean prehospital time was 40.3 min. Mean time from trauma occurrence to tertiary treatment was 125 min. Blunt TT (BTT) was recorded in 59 patients (89.4%), and penetrant TT (PTT) was recorded in 7 patients (10.6%). Thoracic drainage, urgent thoracotomy and laparotomy were recorded procedures. The mean Injury Severity Score (ISS) of all patients was 31.17. Nine patients died (13.6%) and had BTT with a mean ISS of 48.44. The Trauma Injury Severity Score for BTT injuries was 77.08% and for PTT, 85.6%.

Conclusions

Factors that decreased hospital stay and mortality and increased survival included arriving in time after injury, aggressive reanimation/intensive care, and mandatory thoracic surgical procedure combined with laparotomy.

[Interventional management of secondary retentions after thoracic and abdominal trauma]

BACKGROUND

Percutaneous treatment of secondary thoracic and abdominal retention formations after blunt or penetrating trauma now represents a standard interventional radiological procedure. Various supportive imaging procedures are available, whereby computed tomography is mostly the treatment of choice due to the high diagnostic sensitivity.

OBJECTIVE

Based on clinical examples this review article gives an overview of the state of the art minimally invasive interventional treatment of secondary posttraumatic retention formations of the thorax and abdomen. The indications and contraindications are illustrated and typical techniques and access routes are described.

MATERIAL AND METHODS

Besides the general introduction and technical part, the article is divided into the anatomical compartments thorax and abdomen and frequently asked questions are dealt with.

CONCLUSION

After the study of this article you should have got to know and understand the indications for a minimally invasive approach, the possible techniques and necessary materials as well as the indications and contraindications.

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review

PURPOSE

The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients.

METHODS

A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal.

RESULTS

Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention.

CONCLUSION

In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed.

LEVEL OF EVIDENCE

Systematic review study, level IV.

Candida Albicans Osteomyelitis after Chest Wall Blunt Trauma: A Case Report

Fungal osteomyelitis is a rare disease that can occur in immunocompromised patients. We report a case of a patient with a primary rib osteomyelitis after a blunt trauma of the chest wall. Aggressive surgical debridement along with antifungal therapy was the cornerstone of the disease management in this patient.

Rib Cortical Bone Fracture Risk as a Function of Age and Rib Strain: Updated Injury Prediction Using Finite Element Human Body Models

To evaluate vehicle occupant injury risk, finite element human body models (HBMs) can be used in vehicle crash simulations. HBMs can predict tissue loading levels, and the risk for fracture can be estimated based on a tissue-based risk curve. A probabilistic framework utilizing an age-adjusted rib strain-based risk function was proposed in 2012. However, the risk function was based on tests from only twelve human subjects. Further, the age adjustment was based on previous literature postulating a 5.1% decrease in failure strain for femur bone material per decade of aging. The primary aim of this study was to develop a new strain-based rib fracture risk function using material test data spanning a wide range of ages. A second aim was to update the probabilistic framework with the new risk function and compare the probabilistic risk predictions from HBM simulations to both previous HBM probabilistic risk predictions and to approximate real-world rib fracture outcomes. Tensile test data of human rib cortical bone from 58 individuals spanning 17-99 years of ages was used. Survival analysis with accelerated failure time was used to model the failure strain and age-dependent decrease for the tissue-based risk function. Stochastic HBM simulations with varied impact conditions and restraint system settings were performed and probabilistic rib fracture risks were calculated. In the resulting fracture risk function, sex was not a significant covariate-but a stronger age-dependent decrease than previously assumed for human rib cortical bone was evident, corresponding to a 12% decrease in failure strain per decade of aging. The main effect of this difference is a lowered risk prediction for younger individuals than that predicted in previous risk functions. For the stochastic analysis, the previous risk curve overestimated the approximate real-world rib fracture risk for 30-year-old occupants; the new risk function reduces the overestimation. Moreover, the new function can be used as a direct replacement of the previous one within the 2012 probabilistic framework.

Rib fracture fixation in a patient on veno-venous ECMO for severe blunt thoracic trauma

Thoracic chest wall trauma is a common injury in patients admitted to hospital following injury and is associated with high mortality. British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines recommend consideration of rib fracture fixation in patients with flail chest wall injuries with respiratory compromise or uncontrollable pain. Veno-venous extracorporeal membrane oxygenation (ECMO) can be utilised in patients with severe respiratory dysfunction and we present the case of a patient who underwent rib fracture fixation while receiving ECMO. A 32-year-old male was admitted to our department following a 4.5m fall. He sustained significant thoracic injuries with multiple ribs fractures and a flail segment from the right fourth to ninth ribs. Treatment consisted of bilateral chest drains, ECMO support, tracheostomy and rib fracture fixation to the eighth and ninth ribs. The patient made a rapid recovery following surgery and ECMO support was ceased 2.5 days postoperatively. The case shows that a well-prepared, combined specialty surgical team can safely perform rib fixation for a patient on ECMO.

A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients

BACKGROUND

Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change.

METHODS

A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS.

RESULTS

There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198.

CONCLUSION

Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period.

LEVEL OF EVIDENCE

Therapeutic/Care Management. Trauma, Rib, Triage, level IV.

Application and outcomes of extracorporeal life support in emergency general surgery and trauma

BACKGROUND

We analyzed the use of Extracorporeal Membranous Oxygenation (ECMO) in acute care surgery patients at our Level-1 trauma center. We hypothesized that this patient population has improved ECMO outcomes.

METHODS

This was a retrospective analysis of emergency general surgery and trauma patients placed on ECMO between the periods of October 2013 and February 2020. There were 10 surgical and 12 trauma patients studied, who eventually required ECMO support. ECMO support and ECMO type/modality were analyzed with injury and survival prognostic scores examined.

MAIN RESULTS

Overall, 16 of the 22 patients survived to hospital discharge, for a survival rate of 73%. Mean age was 34.18 years. Mean hospital length of stay was 23.4 days with mean days on ECMO equal to 7.5. The net negative fluid balance was 5.36 L.

CONCLUSIONS

The survival of our ECMO cohort is notably higher than previously cited studies. Our group demonstrated decreased length of time on ECMO, decreased length of stay in the hospital, and similar rates of complications compared to prior reports. ECMO is a useful modality in acute care surgical patients and should be considered in these patient populations. Our focus on net negative fluid balance for ECMO patients demonstrates improved survival. ECMO should be considered early in surgical patients and early in advanced trauma life support.

Epidemiological profile of chest trauma and predictive factors for length of hospital stay in a hospital in Southern Brazil

INTRODUCTION

Thoracic trauma is one of the most common types, corresponding to 10% of the traumas admitted in emergency services.

OBJECTIVE

To analyse epidemiologic aspects of patients diagnosed with chest trauma in a hospital at the south of Brazil and its predictive factor for prolonged length of stay.

METHODS

We conducted a retrospective cohort involving patients who were victims of chest trauma. They were described by the International Classification of Diseases (ICD) from S20 to S29 admited in a regional hospital in Southern Brazil, from January 2008 to December 2018. The analysed variables were: sex, age, ICD, type of trauma, complication, need for intensive care unit (ICU), mechanical ventilation (MV) and oxygen therapy (O2), scores on Injury Severity Score (ISS) and Thoracic Trauma Severity Score (TTSS) and outcomes length of stay and death.

RESULTS

121 patients were evaluated, with median age 47.0 (35-0-58.5) years, where 84.3% being of them were male. Blunt trauma had a higher prevalence with 85.1%, with the most frequent complication being spine fractures (30.4%), followed by rib fractures (23.2%) and pneumothorax (16.8%). There was need of ICU in 14%, use of O2 in 30.6% and need of MV in 5.8%. The median length of stay was 6.0 (4.0-10.5), and death as an outcome was found in only 1.7%. Relying on the TTSS, the median (p25-p75) found was 3.0 (2.0-5.0) points and the ISS score was 4.0 (0.0-9.0). If observing patients with a length of stay ≥ 6 days, there were an association with the female gender, need of ICU, O2 and MV, ISS scores, and TTSS scores in the categories who involved pleural commitment and minor PaO2/FiO2.

CONCLUSION

Most of the victims were male young adults with low mortality. The TTSS and ISS were found to be adequate predictors of prolonged length of stay.

Implementation of an algorithm for chest imaging in blunt trauma decreases use of CT-scan: Resource management in a middle-income country

PURPOSE

Due to the low sensitivity of chest radiography, chest CT-scan is usually recommended for the evaluation of high-risk blunt trauma patients. Considering the radiation exposure and costs accompanying routine CT-scan, the aim of this study was to design and implement an evidence-based institutional algorithm for selective chest imaging in high energy blunt trauma patients and evaluate its effect on patient outcome and resource utilization.

METHODS

For this field trial, an institutional evidence-based algorithm for chest trauma imaging was designed according to existing data and expert panel. After final consent and ethic committee approval, the algorithm was integrated in the diagnostic flow sheet in the emergency department and patient data were collected from the pre- and post-implementation period.

RESULTS

One-hundred and sixty-five patients before algorithm implementation and 158 patients after that were included. Chest CT-scan was requested for 93% of patients in the pre-implementation group and for 73% in the post-implementation group (P<0.001). Length of stay in hospital was slightly shorter in the post-implementation group (p = 0.036), however, duration of stay in emergency room and ICU, pulmonary complications and mortality showed no significant difference.

CONCLUSION

Implementation of an algorithm for limiting chest CT-scan to a subgroup of patients with a higher risk of chest injuries can reduce radiation exposure and more useful distribution of resources without harming the patients. Each institution should use institutional guidelines and algorithms with respect to patient load, available resources and desired sensitivity for injury detection.

Where is the chest tube? Ectopic chest tube

Tension pneumothorax is one of the commonest life-threatening condition seen in multiple injury or polytrauma trauma victims. Chest tube insertion has been the mainstay treatment for tension pneumothorax since early 1970s until today. Despite being a common procedure performed by an emergency resident, the incidence of complications related to the procedure remains significantly high. Iatrogenic complications are particularly more common in patients that are critically ill, obese or with a flail chest. This report will be discussing on an ectopic chest tube insertion during management of a case of traumatic tension pneumothorax in an obese patient with flail chest. Further discussions are on various recent updates on chest tube insertion procedures in an emergency setting. It is vital to understand that prior to chest tube insertion, it is important to acknowledge a possibility of complicated procedure by stratifying the risk of individual patients. Hence, this may reduce the risk of iatrogenic complications.

Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients

The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36–68), the overall Injury Severity Score (ISS) was 24 points (IQR 17–29), and a median BMI of 25.1 points (IQR 23–28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued.

Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study

Abstract

Objectives

Thoracic trauma (TT) is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Its management is still a very challenging task. The purpose of this study was to analyse the risk factors affecting the outcome in a high-volume trauma centre and the efficacy of a specialised trauma team in level 1 trauma centres.

Patients and methods

Between January 2003 and December 2012, data of all patients admitted to the accident and emergency (A&E) department were prospectively collected at the German Trauma Registry (GTR) and thereafter retrospectively analysed.

Patients with chest trauma, an Injury Severity Score (ISS) ≥ 18 and an Abbreviated Injury Scale (AIS) > 2 in more than one body region were included. Patients were divided into two groups: group I included patients presenting with thoracic trauma between January 2003 and December 2007. The results of this group were compared with the results of another group (group II) in a later 5-year period (Jan. 2008–Dec. 2012). Univariate and multivariate analyses were performed, and differences with p < 0.05 were considered statistically significant.

Results

There were 630 patients (56%) with thoracic trauma. A total of 540 patients (48%) had associated extrathoracic injuries. Group I consisted of 285 patients (197 male, mean age 46 years). Group II consisted of 345 patients (251 male, mean age 49 years). Overall 90-day mortality was 17% (n = 48) in group I vs. 9% (n = 31) in group II (p = 0.024). Complication rates were higher in group I (p = 0.019). Higher Injury Severity Scores (ISSs) and higher Abbreviated Injury Acale (AIS) scores in the thoracic region yielded a higher rate of mortality (p < 0.0001). Young patients (< 40 years) were frequently exposed to severe thoracic injury but showed lower mortality rates (p = 0.014). Patients with severe lung contusions (n = 94) (15%) had higher morbidity and mortality (p < 0.001). Twenty-three (8%) patients underwent emergency thoracotomy in group I vs. 14 patients (4%) in group II (p = 0.041). Organ replacement procedures were needed in 18% of patients in group I vs. 31% of patients in group II (p = 0.038).

Conclusions

The presence of severe lung contusion, a higher ISS and AIS_thoracic score and advanced age are independent risk factors that are directly related to a higher mortality rate. Management of blunt chest trauma with corrective chest tube insertion, optimal pain control and chest physiotherapy results in good outcomes in the majority of patients. Optimal management with better survival rates is achievable in specialised centres with multidisciplinary teamwork and the presence of thoracic surgical experience.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Profile of Chest Injuries and Oxygen Therapy in Trauma Patients with Acute Respiratory Failure after the Jiangsu Tornado in China: A Retrospective Study

BACKGROUND

The aim of this study was to analyze the profile of chest injuries, oxygen therapy for respiratory failure, and the outcomes of victims after the Jiangsu tornado, which occurred on June 23, 2016 in Yancheng City, Jiangsu Province, China.

METHODS

The clinical records of 144 patients referred to Yancheng City No.1 People's Hospital from June 23 through June 25 were retrospectively investigated. Of those patients, 68 (47.2%) sustained major chest injuries. The demographic details, trauma history, details of injuries and Abbreviated Injury Scores (AIS), therapy for respiratory failure, surgical procedures, length of intensive care unit (ICU) and hospital stay, and mortality were analyzed.

RESULTS

Of the 68 patients, 41 (60.3%) were female and 27 (39.7%) were male. The average age of the injured patients was 57.1 years. Forty-six patients (67.6%) suffered from polytrauma. The mean thoracic AIS of the victims was calculated as 2.85 (SD = 0.76). Rib fracture was the most common chest injury, noted in 56 patients (82.4%). Pulmonary contusion was the next most frequent injury, occurring in 12 patients (17.7%). Ten patients with severe chest trauma were admitted to ICU. The median ICU stay was 11.7 (SD = 8.5) days. Five patients required intubation and ventilation, one patient was treated with noninvasive positive pressure ventilation (NPPV), and four patients were treated with high-flow nasal cannula (HFNC). Three patients died during hospitalization. The hospital mortality was 4.41%.

CONCLUSIONS

Chest trauma was a common type of injury after tornado. The most frequent thoracic injuries were rib fractures and pulmonary contusion. Severe chest trauma is usually associated with a high incidence of respiratory support requirements and a long length of stay in the ICU. Early initiation of appropriate oxygen therapy was vital to restoring normal respiratory function and saving lives. Going forward, HFNC might be an effective and well-tolerated therapeutic addition to the management of acute respiratory failure in chest trauma.

The incidence and predictors of pneumothorax among trauma patients in Saudi Arabia. Findings from a level-I trauma center

ABSTRACT

A University Hospital Based Study on Thoracic Trauma: Life Threatening Event, Its Etiology, Presentation, and Management

INTRODUCTION

Thoracic injury is becoming an important cause of mortality in Pakistan, especially in the younger subset of population. The initial management of these injuries is essential as these patients can develop multiple complications, ultimately leading to death of the patients.

MATERIALS AND METHODS

This prospective observational study was carried out from January 2016 to December 2018 at the Department of Surgery, Holy Family Hospital, Rawalpindi Medical University, Pakistan. It included all the patients over 12 years of age who had thoracic trauma, who presented in the ED, and were admitted to the surgical ward and intensive care unit (ICU). Data were collected with the help of a pre-designed proforma. After relevant investigations and treatment, data were collected and analyzed through Statistical Package for Social Sciences (SPSS) for version 19. Nominal variables were reported as frequencies and percentages.

RESULTS

Out of a total of 330 patients, 188 (56.9%) suffered from blunt injuries whereas 142 (43%) had penetrating injuries. The most common cause of these injuries was road traffic accidents -- 105 (32%) followed by falls -- 23 (76%). Most of the injuries encountered were isolated pneumothorax -- 74 (22.4%) followed by rib fractures with pneumothorax -- 71 (21.5%). Tube thoracostomy was done in 189 cases (57.3%) whereas 94 (28.5%) patients were managed conservatively. Complications were seen in 117 patients (35.4%). Out of these 117 cases, death was the major complication - 30 (25.6%) followed by bronchopleural fistula - 24 (20.5%) and empyema thoracis - 22 (18.8%).

CONCLUSION

Road traffic accidents are a major cause of thoracic injuries in our setting. Tube thoracostomy is the most commonly used treatment modality. Mortality rate is high in the patients with thoracic injuries.

Inequality of trauma care under a single-payer universal coverage system in Taiwan: a nationwide cohort study from the National Health Insurance Research Database

​OBJECTIVES: To assess the impact of lower socioeconomic status on the outcome of major torso trauma patients under the single-payer system by the National Health Insurance (NHI) in Taiwan. ​DESIGN: A nationwide, retrospective cohort study. ​SETTING: An observational study from the NHI Research Database (NHIRD), involving all the insurees in the NHI. ​PARTICIPANTS: Patients with major torso trauma (injury severity score ≥16) from 2003 to 2013 in Taiwan were included. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify trauma patients. A total of 64 721 patients were initially identified in the NHIRD. After applying the exclusion criteria, 20 009 patients were included in our statistical analysis. ​PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was in-hospital mortality, and we analysed patients with different income levels and geographic regions. Multiple logistic regression was used to control for confounding variables. ​RESULTS: In univariate analysis, geographic disparities and low-income level were both risk factors for in-hospital mortality for patients with major torso trauma (p=0.002 and <0.001, respectively). However, in multivariate analysis, only a low-income level remained an independent risk factor for increased in-hospital mortality (p<0.001). ​CONCLUSION: Even with the NHI, wealth inequity still led to different outcomes for major torso trauma in Taiwan. Health policies must focus on this vulnerable group to eliminate inequality in trauma care.

Combined Extra- and Intrapleural Hematoma After Blunt Chest Injury in an Anticoagulated Patient

The objective of this study was to describe the atypical presentation of combined intrapleural and extrapleural hematomas in patients on anticoagulant therapy and explain the best workup and treatment for this pathology. This case report details the presentation, initial treatment, initial workup, and subsequent final treatment and workup of an elderly female patient that arrived at our trauma facility after suffering a blunt force trauma. The patient received anticoagulation therapy for her comorbidities prior to this incident. The outcome of interest was to better understand the best diagnostic and treatment modalities for treating combined intrapleural and extrapleural hematomas

Prediction of outcomes in chest trauma patients using chest trauma scoring system: A prospective observational study

Background and Aims:

Prognostication of chest trauma patients by scoring systems is of vital importance to predict morbidity and mortality. We aimed to predict outcomes in chest trauma patients using chest trauma scoring system (CTS) in Indian patients.

Methods:

This was a prospective observational study done in a trauma care centre at a tertiary care teaching public hospital. CTS was calculated by scores of age, severity of pulmonary contusion, number of rib fractures and presence of bilateral rib fractures. Final CTS ranges from 2 to 12. We evaluated CTS to predict outcome that is mortality as primary objective and development of complications like pneumonia and need for ventilator support as secondary objective in Indian population.

Results:

Data were collected from 30 patients and they were divided into two groups, CTS <5 (15) and CTS ≥5 (15). High CTS ≥5 was statistically significantly associated with high incidence of pneumonia (P = 0.046), increased requirement of mechanical ventilation (P = 0.025) and mortality (P = 0.035) in chest trauma. Area under the ROC for mortality shows that the test is acceptable (0.75) and at CTS score 5.5 maximum sensitivity is 87.5% and specificity is 68%.

Conclusion:

This study concludes that a CTS ≥5 is associated with poor outcomes. This scoring system may be used to identify patients at risk of complications and institute early intensive focussed care.

Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults

OBJECTIVES

Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.

DESIGN

A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.

RESULTS

Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.

CONCLUSIONS

Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.

PROSPERO REGISTRATION NUMBER

CRD42016053494.

Analysis of trauma patients with unplanned returns to the operating room

Objectives

Trauma patients undergoing damage-control surgery may have a planned return to the operating room. In contrast, little is known about unplanned returns to the operating room (uROR) in trauma. The aim of this study was to identify risk factors for uROR in trauma patients. It is hypothesized that blunt trauma patients with uROR have higher mortality when compared to penetrating trauma patients with uROR. Additionally, it is hypothesized that trauma patients with uROR after thoracotomy have higher mortality than patients with uROR after laparotomy.

Material and Methods

A retrospective analysis of the National Trauma Data Bank from 2011-2015 including any adult patient with an uROR was performed.

Results

From 3.447.320 patients, 9.269 (0.2%) were identified to have uROR. In a multivariable logistic regression analysis, 27 independent predictors were identified for risk of uROR with the strongest independent risk factor being compartment syndrome (OR= 10.50, CI= 9.35-11.78, p <0.001). Blunt (compared to penetrating) mechanism was associated with higher risk for mortality in patents with uROR (OR= 1.69, CI= 1.14-2.51, p <0.001) as was re-incision thoracotomy (RT) compared to re-incision laparotomy (RL) (OR= 2.22, CI= 1.29-3.84, p <0.001).

Conclusion

The strongest risk factor for uROR in trauma is compartment syndrome. Both a blunt (compared to penetrating) mechanism and RT (compared to RL) are independent risk factors for mortality in patients undergoing an uROR.

Epidural Analgesia With Surgical Stabilization of Flail Chest Following Blunt Thoracic Trauma in Patients With Multiple Trauma

Flail chest, often defined as the fracture of three or more ribs in two or more places, represents the most severe form of rib fractures. Conservative treatment, consisting of respiratory assistance with endotracheal intubation and mechanical ventilation (internal pneumatic stabilization) and pain control, are the current treatments of choice in the majority of patients with multiple rib fractures. However, the use of mechanical ventilation may create complications. In selected patients, operative fixation of fractured ribs within 72 h post injury may lead to better outcomes. We conducted a retrospective analysis of a series of nine cases of patients who developed flail chest after blunt trauma, and were treated with surgical osteofixation of the chest wall and postoperative epidural analgesia at the University Clinical Center of the Republic of Srpska during the period from January 2015. to December 2016. Two patients had trauma to the chest only, and the other patients had associated injuries to the head, abdomen, spine, and fractures of the pelvis and long bones. In the majority of patients (77.7%), surgical stabilization of the chest was performed on the second day following the injury, (mean, 2.33 days) and no later than 5 days after the injury. All patients received epidural analgesia with 0, 25% bupivacaine and 0, 01% morphine and intravenous multimodal analgesia, beginning 6 h after thoracotomy. The average length of ICU stay was 14.7 days (range 2–36), while the average number of days of mechanical ventilation was 8.1. The average duration of hospitalization was 25.4 days. Tracheotomy was performed in 33.3% of study patients. Mortality in the observed group was 44.4%. This study shows that surgical stabilization and epidural analgesia reduced ventilator support, shortened trauma intensive care unit stay, and reduced medical costs vs internal pneumatic stabilization.

Emergency Medical Services Simple Thoracostomy for Traumatic Cardiac Arrest: Postimplementation Experience in a Ground-based Suburban/Rural Emergency Medical Services Agency

BACKGROUND

Tube thoracostomy has long been the standard of care for treatment of tension pneumothorax in the hospital setting yet is uncommon in prehospital care apart from helicopter emergency medical services.

OBJECTIVE

We aimed to evaluate the performance of simple thoracostomy (ST) for patients with traumatic cardiac arrest and suspected tension pneumothorax.

METHODS

We conducted a retrospective case series of consecutive patients with traumatic cardiac arrest where simple thoracostomy was used during the resuscitation effort. Data were abstracted from our Zoll emergency medical record (Zoll Medical Corp., Chelmsford, MA) for patients who received the procedure between June 1, 2013 and July 1, 2017. We collected general descriptive characteristics, procedural success, presence of air or blood, and outcomes for each patient.

RESULTS

During the study period we performed ST on 57 patients. The mean age was 41 years old (range 15-81 years old) and 83% were male. Indications included 40 of 57 (70%) blunt trauma and 17 of 57 (30%) penetrating trauma. The presenting rhythm was pulseless electrical activity 65%, asystole 26%, ventricular tachycardia/fibrillation 4%, and nonrecorded 5%. Eighteen of 57 (32%) had air return, 14 of 57 (25%) return of spontaneous circulation, with 6 of 57 (11%) surviving to 24 h and 4 of 57 (7%) discharged from the hospital neurologically intact. Of the survivors, all were blunt trauma mechanism with initial rhythms of pulseless electrical activity. There were no reported medic injuries.

CONCLUSIONS

Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. We found a significant (32%) presence of pneumothorax in our sample, which supports previously reported high rates in this patient population.

Orem’s Self-Care Model With Trauma Patients: A Quasi-Experimental Study

To examine if the application of Orem’s self-care model could improve self-care knowledge, attitudes, practices, and respiratory conditions of trauma patients with chest tubes, a quasi-experimental study was conducted. The participants were assigned to two groups—namely, Orem’s model and routine care. Although the patients’ self-care knowledge, attitudes, and practices were improved in both groups over the course of 3 days since the initial assessments, there was a greater degree of improvement in the experimental group than that in the control group. However, there were no differences in the improvement of the chest parameters between the two groups. Orem’s model was effective in improving self-care in patients with chest tube.

Systematic review and meta-analysis of tube thoracostomy following traumatic chest injury; suction versus water seal

Purpose

Tube thoracostomy is frequently used in thoracic trauma patients. However, there is no consensus on whether low pressure suction or water seal is the optimal method of tube management. Against this background, we performed a systematic review of studies comparing suction and water seal management of chest tubes placed for traumatic chest injuries in adults. Evaluated outcomes are duration of chest tube treatment, length of stay in hospital, incidence of persistent air leak, clotted hemothorax, and the need for (re-)interventions.

Methods

A systematic literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed. Included studies were evaluated according to the Cochrane Collaboration’s tool for assessing the risk of bias, and according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for assessing the quality of evidence.

Results

After assessment of 120 identified studies, three RCT’s (randomized controlled trials) were included in this review and meta-analysis. A favorable effect of suction was found for duration of chest tube treatment [MD (mean difference) − 3.38 days, P = 0.005], length of stay in hospital (MD −3.90 days, P = 0.0003), and the incidence of persistent air leak [OR (odds ratio) 0.27, P = 0.001]. No significant difference was found for the incidence of clotted hemothorax and (re-)interventions. The quality of evidence according to GRADE was low, except for persistent air leak (moderate).

Conclusions

Suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital and persistent air leakage in chest trauma. However, available data was limited and the quality of evidence was (very) low to moderate according to GRADE.

An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20-25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity.

Severe thoracic trauma - still an independent predictor for death in multiple injured patients?

Background

Over the past, the severe thoracic trauma has had decisive influence on the outcome of multiple injured patients. Today, new therapies (e.g. extracorporeal membrane oxygenation (ECMO), protective ventilation methods and new forms of patient positioning) are available and applied regularly. What impact on the patient’s outcome does the thoracic trauma have today?

Methods

Prospective data collection of multiple injured patients in a level-I trauma center was performed between 2008 and 2014. Patients with an ISS ≥16 were included and divided into 2 groups: Severe thoracic trauma (STT: AIS_Thorax ≥ 3) and mild thoracic trauma (MTT: AIS_Thorax < 3). In addition to preclinical and trauma room care, detailed information about clinical course and outcome were assessed.

Results

In total, 529 patients (STT: n = 317; MTT: n = 212) met the in- and exclusion criteria. The mean Injury Severity Score (ISS) was significantly higher in patients of the STT group (STT: 33.5 vs. MTT: 24.7; p < 0.001), while the RISC II Score showed no significant differences (STT: 20.0 vs. MTT: 17.1; p = 0.241). Preclinical data revealed a higher intubation rate, more chest tube insertions and a higher use of catecholamines in the STT group (p < 0.05). Clinically, we found significant differences in the duration of invasive ventilation (STT: 7.3d vs. MTT: 5.4d; p = 0.001) and ICU stay (STT: 12.3d vs. MTT: 9.4d; p < 0.001). While the complication rate was higher for the STT group (sepsis (STT: 11.4% vs. MTT: 5.7%; p = 0.017); lung failure (STT: 23.7% vs. MTT: 12.3%; p = 0,001)), neither the non-adjusted lethality rate (STT: 13.2% vs. MTT: 13.7%; p = 0.493) nor the Standardized Mortality Ratio (SMR) showed significant differences (STT: 0.66 vs. MTT: 0.80; p = 0.397). The multivariate regressive analysis confirmed that severe thoracic trauma is not an independent risk factor for lethality in our patient cohort.

Conclusion

Despite a higher injury severity, the extended need of emergency measures and a higher rate of complications in injured patients with severe blunt thoracic trauma, no influence on lethality can be proved. The reduction of the complication rate should be a goal for the next decades.