Diagnostic Dilemmas and Current Controversies in Blunt Chest Trauma

Sudden death associated with delayed cardiac rupture: case report and literature review

Cardiac injury plays a critical role in the process of thoracic trauma-related fatal outcomes. Historically, most patients who suffer a cardiac rupture typically die at the scene of occurrence or in the hospital, despite prompt medical intervention. Delayed cardiac rupture, although rare, may occur days after the initial injury and cause sudden unexpected death. Herein, we present the clinical details of a young man who suffered a chest stab injury and recovered well initially, but died days later due to delayed cardiac rupture. The forensic autopsy confirmed delayed cardiac rupture as the cause of death. We also reviewed previous similar reports to provide suggestions in such rare cases in clinical and forensic practice.

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH₂O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis

BACKGROUND

Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective.

METHODS

We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations.

CONCLUSION

In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.

Efficacy of high-flow nasal prong therapy in trauma patients with rib fractures and high-risk features for respiratory deterioration: a randomized controlled trial

BACKGROUND

Patients with rib fractures require analgesia, oxygen supplementation and physiotherapy. This combination has been shown to reduce morbidity and mortality due to rib fractures. There has been movement towards the use of high-flow nasal prong (HFNP) oxygen. However there are no studies demonstrating the effectiveness of HFNP in this population. The aim of this study was to compare HFNP to venturi mask (VM) in rib fracture patients.

METHODS

Randomized controlled trial. Patient population included patients with rib fractures and high-risk features (three or more rib fractures, flail segment, bilateral rib fractures, smoker or chronic obstructive pulmonary disease). Exclusion criteria included initial mechanical ventilation and contraindications to HFNP. Patients were randomized to HFNP or VM. Primary outcome was deterioration requiring mechanical invasive/non-invasive ventilation, or unplanned admission to intensive care unit. Secondary outcomes included mortality, length of stay, high dependency length of stay, comfort levels, breathing exertion levels (as measured by Borg Scale), oxygen saturation, respiratory rate, heart rate, chest X-ray and arterial blood gas parameters.

RESULTS

220 patients (average age 60 years and average of four rib fractures each) were randomized to HFNP (n=113) and VM (n=107). There was no statistically significant difference in the primary outcome comparing HFNP and VM (6.2% vs. 6.5%, p=1.0). There were also no statistically significant differences in the secondary outcomes except for PaCO₂ (43.6 vs. 45.5, p=0.039).

CONCLUSION

HFNP oxygen supplementation does not appear to be more effective than VM oxygen supplementation in patients with rib fractures.

A case of fatal trauma evaluated using a portable X-ray system at the scene

Objective: To demonstrate the use of a portable X-ray system at the scene.

Patient: A 59-year-old man collapsed under a small power shovel and was discovered by his colleague. The fire department dispatched an ambulance and requested the dispatch of a doctor helicopter (DH) immediately after receiving the emergency call. When the staff of the DH used a portable X-ray system to assess the patient at the rendezvous point, he was found to have experienced a cardiac arrest with deformity of the face. Portable chest X-ray in the ambulance revealed decreased radiolucency of the lung fields without pneumothorax, and tracheal tube insertion was successful. Portable pelvic X-ray also showed no trauma. Portable cranial X-ray revealed orbital fracture. Although we urgently transported the patient to our hospital by the DH, he unfortunately died of circulatory arrest caused by his severe injuries. Based on the portable X-ray findings obtained at the scene, we suspected that the patient’s cardiac arrest had been caused by severe head and/or neck injuries.

Conclusion: This portable X-ray system may be able to change and facilitate the management of patients with trauma dramatically by simplifying prehospital diagnoses even in rural areas.

Chest Tube Management Practices by Trauma Surgeons

BACKGROUND

Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers.

MATERIALS AND METHODS

We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used.

RESULTS

The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice.

CONCLUSIONS

Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study

BACKGROUND

Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard.

METHODS

A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated.

RESULTS

A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively.

CONCLUSION

Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

BACKGROUND

Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.

METHODS

We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients.

RESULTS

BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001).

CONCLUSION

SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI.

SUMMARY

Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.

Do patients with blunt thoracic aortic injury present to hospital with unstable vital signs? A systematic review and meta-analysis

BACKGROUND

Blunt thoracic aortic injury (BTAI) is an uncommon diagnosis, usually developing as a consequence of high-impact acceleration-deceleration mechanisms. Timely diagnosis may enable early resuscitation and reduction of shear forces, essential to prevent worsening of the injury prior to definitive management. Death is commonly due to haemorrhagic shock, but clinical features may be absent until sudden and massive haemorrhage.

OBJECTIVES

The aim of this systematic review was to determine the proportion of patients with BTAI who present with unstable vital signs.

METHODS

Manuscripts were identified through a search of MEDLINE, EMBASE and the Cochrane Library databases, focusing on subject headings and keywords related to the aorta and trauma. Mechanisms of injury, haemodynamic status and mortality from the included manuscripts were reviewed. Meta-analysis of presenting haemodynamic status among a select group of similar papers was conducted.

RESULTS

Nineteen studies were included, with five selected for meta-analysis. Most reported cases of BTAI (80.0%-100%) were caused by road traffic incidents, with mortality consistently higher among initially unstable patients. There was statistically significant heterogeneity among the included studies (P<0.01). The pooled proportion of patients with haemodynamic instability in the setting of BTAI was 48.8% (95% CI 8.3 to 89.4).

CONCLUSIONS

Normal vital signs do not rule out aortic injury. A high degree of clinical suspicion and liberal use of imaging is necessary to prevent missed or delayed diagnoses.

Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period.

METHODS

This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics.

RESULTS

Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors.

CONCLUSION

TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use.

Management of blunt pulmonary injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Cost-effectiveness of the Cardiac Component of the Focused Assessment of Sonography in Trauma Examination in Blunt Trauma

BACKGROUND

Blunt cardiac injury severe enough to require surgical intervention (sBCI) is an exceedingly rare event occurring in approximately 1 out of every 1600 trauma patients. While performing the cardiac component of the Focused Assessment of Sonography in Trauma (cFAST) exam is effective in penetrating trauma, it is unclear whether it is of value in blunt trauma given the low prevalence of sBCI, the imperfect test characteristics of the FAST exam, and the rate of incidental pericardial effusion.

OBJECTIVE

The objective was to determine through decision analysis whether performing the cFAST exam is cost-effective in the evaluation of hypotensive and normotensive blunt trauma patients.

METHODS

We created two decision analytic models using commercially available software (TreeAgePro2011) to evaluate the cost-effectiveness of the cFAST in hypotensive (systolic blood pressure <90 mm Hg) and normotensive blunt trauma patients. Clinical probabilities were obtained from published data. Costs were estimated from Medicare reimbursement and charge data. The willingness-to-pay threshold was $50,000/quality-adjusted life-years (QALYs). Sensitivity analyses were performed over plausible ranges using available literature.

RESULTS

In hypotensive patients, for the base case scenario of a 34-year-old with blunt trauma, the cFAST strategy had a cost of $42,882.70 and an effectiveness of 25.3597 QALYs, whereas the no cFAST strategy had a cost of $42,753.52 and an effectiveness of 25.3532 QALYs. The incremental cost-effectiveness ratio (ICER) was $19,918/QALY. For normotensive patients the cFAST strategy had a cost of $18,331.03 and an effectiveness of 23.2817 QALYs, whereas the no cFAST strategy had a cost of $18,207.58 and an effectiveness of 23.2814 QALYs. The ICER was $465,867/QALY. In the sensitivity analyses, age, probability of death from sBCI with prompt treatment, and probability of sBCI were the main drivers of variability in the model outcomes.

CONCLUSIONS

The cFAST for blunt trauma is cost-effective for hypotensive but not for normotensive patients. The ICER for hypotensive patients was more than 20 times higher than the ICER for normotensive patients. Our results suggest that performing the cFAST exam may not be an effective use of resources in normotensive blunt trauma patients.

Management of Blunt Pulmonary Injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Fatal blunt cardiac injury: are there any subtle indicators?

A 29-year-old man had a head-on collision with an oncoming truck while riding a bike. He sustained a fracture of the left first rib, fracture of the left talar neck with ankle dislocation and fracture dislocation of the right wrist. The patient was haemodynamically stable and underwent an emergency open reduction and internal fixation of the fractured talar neck to prevent further vascular compromise of the lower limb. Postoperatively, the patient deteriorated haemodynamically with persistent tachycardia and respiratory distress and died after 3 days despite ventilator support. The postmortem examination revealed a contused heart with dissection of the coronary arteries. Our case demonstrates that a first rib fracture may be associated with severe thoracic and cardiac injuries which may be masked by less severe but more obvious skeletal injuries.

Video-assisted minithoracotomy for blunt diaphragmatic rupture presenting as a delayed hemothorax

Diaphragmatic ruptures after blunt trauma are rare life-threatening conditions. Most of them occur on the left-sided hemidiaphragm with herniation or associated organ injuries after a motor vehicle accident. We present an unusual case of blunt diaphragmatic rupture resulting in a delayed hemothorax. A 62-year-old man presented with acute dyspnea that initiated while straining to pass stool. He had a bruise on the lower back region of his right thorax after a slip-and-fall accident 7 days previously. Chest computed tomographic scans revealed a right-sided hemothorax without any evidence of herniation or associated organ injuries. Emergency surgery was performed through a video-assisted minithoracotomy. During surgery, we identified a diaphragmatic laceration with a severed blood vessel originating from the right superior phrenic artery. The lesion was repaired with interrupted horizontal mattress sutures. The total amount of bleeding was approximately 2000 mL. The patient had an uneventful recovery with no further bleeding episodes.

The rate of pleural fluid drainage as a criterion for the timing of chest tube removal: theoretical and practical considerations

Clinicians place chest tubes approximately 1 million times each year in the United States, but little information is available to guide their management. Specifically, use of the rate of pleural fluid drainage as a criterion for tube removal is not standardized. Absent such tubes, pleural fluid drains primarily through parietal pleural lymphatics at rates approaching 500 mL of fluid per day or more for each hemithorax. Early removal of tubes does not appear to be harmful. A noninferiority randomized trial currently in progress comparing removal without considering the drainage rate to a conservative threshold (2 mL/kg body weight in 24 hours) may better inform tube management.

Blunt chest wall trauma: A review

Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.

[Chest trauma: who, how and what?]

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Sealed with a kick: a case of posttraumatic coronary artery dissection and cardiomyopathy

Blunt chest trauma can lead to a variety of cardiac injuries, one of which is nonatherosclerotic myocardial infarction caused by intimal laceration and thrombotic process activation. Here we present a case of anterior myocardial infarction secondary to blunt trauma involving a kick to the chest.

Blunt cardiac injury in trauma patients with thoracic aortic injury

Trauma patients with thoracic aortic injury (TAI) suffer blunt cardiac injury (BCI) at variable frequencies. This investigation aimed to determine the frequency of BCI in trauma patients with TAI and compare with those without TAI. All trauma patients with TAI who had admission electrocardiography (ECG) and serum creatine kinase-MB (CK-MB) from January 1999 to May 2009 were included as a study group at a level I trauma center. BCI was diagnosed if there was a positive ECG with either an elevated CK-MB or abnormal echocardiography. There were 26 patients (19 men, mean age 45.1 years, mean ISS 34.4) in the study group; 20 had evidence of BCI. Of 52 patients in the control group (38 men, mean age 46.9 years, mean ISS 38.7), eighteen had evidence of BCI. There was a significantly higher rate of BCI in trauma patients with TAI versus those without TAI (77% versus 35%, P < 0.001).

Acute Anterior Myocardial Infarction after Being Struck on the Chest by a Soccer Ball

Blunt chest wall trauma is one of the non-atherosclerotic causes of myocardial infarction. Motor vehicle accident is the most common cause of myocardial infarction followed by sports injuries. Myocardial infarction can occur due to traumatic coronary artery laceration with thrombus formation or dissection. Lethal complications may result if accompanying myocardial infarction is overlooked in patients whose chest pain is considered to be solely related to the localised blunt chest wall trauma by the physician and the patient. Here we present a case of acute anterior myocardial infarction secondary to a blunt chest trauma after being struck on the chest by a soccer ball during a recreational soccer game and review the current literature on the diagnosis and treatment of traumatic myocardial infarction.

CT imaging of blunt chest trauma

BACKGROUND: Thoracic injury overall is the third most common cause of trauma following injury to the head and extremities. Thoracic trauma has a high morbidity and mortality, accounting for approximately 25% of trauma-related deaths, second only to head trauma. More than 70% of cases of blunt thoracic trauma are due to motor vehicle collisions, with the remainder caused by falls or blows from blunt objects. METHODS: The mechanisms of injury, spectrum of abnormalities and radiological findings encountered in blunt thoracic trauma are categorised into injuries of the pleural space (pneumothorax, hemothorax), the lungs (pulmonary contusion, laceration and herniation), the airways (tracheobronchial lacerations, Macklin effect), the oesophagus, the heart, the aorta, the diaphragm and the chest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The possible coexistence of multiple types of injury in a single patient is stressed, and therefore systematic exclusion after thorough investigation of all types of injury is warranted. RESULTS: The superiority of CT over chest radiography in diagnosing chest trauma is well documented. Moreover, with the advent of MDCT the imaging time for trauma patients has been significantly reduced to several seconds, allowing more time for appropriate post-diagnosis care. CONCLUSION: High-quality multiplanar and volumetric reformatted CT images greatly improve the detection of injuries and enhance the understanding of mechanisms of trauma-related abnormalities.

Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management

BACKGROUND

Blood accumulating inside chest cavities can lead to serious complications if it is not drained properly. Because life-threatening conditions can result from chest tube occlusion after thoracic surgery, large-bore tubes are generally employed to optimize patency.

AIMS

The aim of this study was to better define problems with current paradigms for chest drainage.

MATERIALS AND METHODS

A survey was conducted of North American cardiothoracic surgeons and specialty cardiac surgery nurses. A total of 108 surgeons and 108 nurses responded.

RESULTS

The survey revealed that clogging leading to chest-tube dysfunction is a major concern when choosing tube size. Of surgeons responding, 106 of 106 (100%) had observed chest tube clogging, and 93 of 106 (87%) reported adverse patient outcomes from a clogged tube. Despite techniques such as tube stripping, tapping, and squeezing, up to 51% of surveyed surgeons stated they are not satisfied with currently available tubes and procedures to avoid tube occlusion and some even forbid the stripping maneuver for fear of causing more bleeding by the negative pressures generated. In addition, respondents noted that patients experience increasing discomfort with increasing drain size.

DISCUSSION

The major reason surgeons choose large-diameter chest tubes is linked to concern about the suboptimal available methods to avoid and treat chest-tube clogging. Even though larger tubes are thought to be associated with more pain, physicians generally err on the side of caution to avoid clogging and insert tubes with larger diameters.

CONCLUSION

Results of this survey highlight the frequent problems with clogging with current postsurgical chest drainage systems and suggest the need for innovative solutions to avoid clogging complications and overcome clinician concern and patient pain.

Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize

Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.

The Active Tube Clearance System a Novel Bedside Chest-Tube Clearance Device

Objective

Chest-tube clogging can lead to complications after heart and lung surgery. Surgeons often choose large-diameter chest tubes or place more than one chest tube when concerned about the potential for clogging. The purpose of this report is to describe the design and function of a proprietary active tube clearance system, a novel device that clears clots and debris from chest tubes.

Device Description

The active tube clearance system is a novel chest tube clearance apparatus developed to maintain chest tube patency. Chest tube clearance is achieved by advancing the specially designed clearance member back and forth within the chest tube under sterile conditions, breaking down and pulling clots back toward the drainage receptacle, thereby leaving the inner portion of the chest tube clear of any obstructing material.

Conclusions

By maintaining chest tube patency, chest tube drainage can be performed more safely, and this apparatus may possibly lead to the use of smaller chest tubes and less invasive insertion techniques.

Blunt traumatic cardiac rupture: therapeutic options and outcomes

INTRODUCTION

Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.

METHODS

This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.

RESULTS

The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.

CONCLUSIONS

We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Effective myocardial salvage with percutaneous coronary intervention in late diagnosed acute post-traumatic ST-elevation myocardial infarction

BACKGROUND

Acute post-traumatic ST-elevation myocardial infarction (STEMI) is rare but potentially disastrous in patients with blunt cardiac injury. Sometimes the diagnosis is delayed. Failed myocardial salvage by percutaneous coronary intervention (PCI) within 9 h after the onset of post-traumatic STEMI has been described.

OBJECTIVE

We present a case report of a patient in whom effective myocardial salvage with PCI was obtained in a late diagnosed acute post-traumatic STEMI.

CASE REPORT

We report the case of a young man who was involved in a motorcycle crash, who had a delayed diagnosis of post-traumatic STEMI. Diagnostic coronary angiography was performed to guide treatment strategy. An occluded left anterior descending artery due to a dissection, and an intimal flap at the first diagonal branch were found. A PCI was done 18 h after the onset of the event with striking and immediate improvement of the regional left ventricular wall motion and ejection fraction.

CONCLUSION

After blunt thoracic injury, there is the possibility of an acute post-traumatic STEMI being present when facing a patient with clues of blunt cardiac injury. If the diagnosis of acute post-traumatic STEMI is clinically strong, the patient should be managed individually according to the clinical scenario. Early recognition and prompt management are vital when dealing with patients suffering post-traumatic STEMI.

Successful Management of Occult Pneumothorax without Tube Thoracostomy despite Positive Pressure Ventilation

The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). Observation was successful in 16 of 20 occult pneumothoraces (80%) exposed to positive pressure ventilation within 72 hours of admission. Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.