Critical Decisions in the Management of Thoracic Trauma

Traumatic Cardiac Arrest-A Narrative Review

A paradigm shift in traumatic cardiac arrest (TCA) perception switched the traditional belief of futility of TCA resuscitation to a more optimistic perspective, at least in selected cases. The goal of TCA resuscitation is to rapidly and aggressively treat the common potentially reversible causes of TCA. Advances in diagnostics and therapy in TCA are ongoing; however, they are not always translating into improved outcomes. Further research is needed to improve outcome in this often young and previously healthy patient population.

A rare case of perforating chest wall including pericardial sac with penetrating trivial injury: A case report and literature review

Perforating chest wall injuries involving the pericardial sac in pediatric patients are exceedingly rare and pose a unique clinical challenge. Thoracic trauma in the pediatric population remains a significant cause of morbidity and mortality. We present a case of an 8-year-old boy with an acute history of a sharp injection needle embedded in his chest wall presented with severe chest pain and diaphoresis. Diagnostic evaluations included computed tomography revealed a hyperdense focus with a metallic artefact seen impacted in the interventricular septa and perforating the heart. He underwent a thoracotomy and cardioplegic arrest for needle retrieval and subsequent cardiac repair. Our case underscores the importance of a multidisciplinary approach, meticulous monitoring, and a profound understanding of the unique anatomical considerations in pediatric chest injuries.

Summary

This article presents a rare and challenging case of an 8-year-old male who arrived at the emergency department with a sharp injection needle embedded in his chest wall. Despite being relatively rare in children, thoracic injuries can be severe and potentially life-threatening. A fast and accurate diagnostic approach is crucial to prevent fatal complications. Thoracic trauma in the pediatric population remains a significant cause of morbidity and mortality. Timely diagnosis and appropriate interventions are critical in improving patient outcomes. The presented case highlights the need for caution and a well-planned approach in managing such rare and complex injuries in children.

Successful management of a thoracoabdominal impalement injury

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival?

PURPOSE

To investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated.

METHODS

A retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted.

RESULTS

Fifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma.

CONCLUSION

This study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.

Major penetrating thoracic trauma - The importance of collaboration between different specialties

Introduction

Penetrating thoracic trauma presents a rare and serious condition with great diversity in impalement mechanisms and following injuries, resulting in a high mortality. This case reports successful management of a severe thoracic trauma and need for collaboration between surgical specialties.

Presentation of case

An 18-year-old, otherwise healthy, Caucasian female had penetration of the chest with a wooden post due to a solo car accident and was admitted to a Level 1 trauma center at a university hospital. Trauma computed tomography scan showed costa fractures and fracture of the left clavicular bone. Damage to the subclavian artery, the brachial plexus and pulmonary artery were suspected. Extracorporeal circulation was on standby at surgery. However, removal of the foreign object did not result in any major bleeding. The patient was discharged from hospital on the 19th day after surgery. Fifteen months after the trauma, surgery was performed to remove the first two costae on the left side, as a disfiguring prominence on the neck was the patients' only complaint.

Discussion

Initial management of the patient should follow ATLS® principles with stabilization of airways, breathing and circulation. Multidisciplinary approach resulted in reconstruction of vessels, debridement and wound closure. The importance of follow-up after trauma and surgery are underlined by the current case, as the patient required additional surgery at follow up.

Conclusion

Multidisciplinary approach to the current penetrating trauma resulted in rapid assessment of injuries and management with excellent outcome.

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

Gluteal, abdominal, and thoracic multiple impalement injuries: A case report on management of a complex polytrauma

RATIONALE

Historically, traumatic injuries include penetrating and blunt lesions. Impalement injury represents one of the rarest and potentially dramatic forms of penetrating trauma. If patient reaches hospital alive and is hemodynamically stable, there is a good chance that patient overcomes the traumatic event. However, non-removal of foreign body represents the cornerstone in initial treatment of this type of patients.

PATIENT CONCERNS

A stable 55-year-old woman was admitted to the Emergency Department after falling out of a tree onto a wooden fence. One fence pole transfixed left gluteus, left abdominal wall, left abdominal cavity, and left thoracic wall by transdiaphragmatic way.

DIAGNOSIS

Due to patient stability, a chest-abdomen CT scan with contrast medium was performed. It showed multiple parietal and visceral traumatic penetrating injuries from a foreign object.

INTERVENTIONS

After primary and secondary advanced trauma life support (ATLS) assessment, patient underwent successful surgery.

OUTCOMES

Patient was discharged on 9th postoperative day in good general clinical condition.

LESSONS

Impalement injury represents a rare and potentially lethal traumatic event. Unstable patients rarely reach Emergency Department alive. On the contrary, stable patients have a good chance of successful treatment, if they are quickly taken to tertiary Trauma Center. In this case, chest X-ray and Focused Assessment with Sonography for Trauma (FAST) represent useful diagnosing investigations, although CT scan remains gold standard. Conservative treatment is not possible, while thoracoscopy/laparoscopy/laparotomy is/are mandatory.

The combined utility of extended focused assessment with sonography for trauma and chest x-ray in blunt thoracic trauma

BACKGROUND

Portable chest x-ray (CXR) and extended focused assessment with sonography for trauma (EFAST) screen patients for thoracic injury in the trauma bay. It is unclear if one test alone is sufficient, if both are required, or if the two investigations are complementary. Study objectives were to define the combined diagnostic yield of EFAST and CXR among stable blunt thoracic trauma patients and to determine if a normal EFAST and CXR might obviate the need for computed tomography (CT) scan of the chest.

METHODS

All blunt trauma patients 15 years or older presenting to LAC+USC Medical Center in 2016 were screened. Only patients who underwent CT thorax were included. Patients were excluded if they presented more than 24 hours after injury, were transferred, or if they did not undergo EFAST and CXR. Demographics, physical examination (PEx) of the thorax, injury data, investigations, procedures, and outcomes were collected. The EFAST, CXR, and PEx findings were compared to the gold standard CT thorax to calculate the diagnostic yield of each investigation and combinations thereof in the assessment for clinically significant thoracic injury.

RESULTS

One thousand three hundred eleven patients met inclusion/exclusion criteria. Most common mechanisms of injury were motor vehicle collision (n = 385, 29%) and auto versus pedestrian trauma (n = 379, 29%). Mean Injury Severity Score was 11 (1-75), with mean Abbreviated Injury Scale chest score of 1.6 (1-6). The sensitivities of EFAST, CXR, and PEx, either individually or in combination, were less than 0.73 in the detection of clinically significant thoracic injury. The most common missed clinically significant injuries were sternal fractures, scapular fractures, clavicular fractures, and pneumothoraces. Motorcycle collisions and auto versus pedestrian traumas resulted in the highest rates of missed injury.

CONCLUSION

Even in conjunction with the physical examination, the sensitivity of EFAST+CXR in the detection of clinically significant thoracic injury is low. Therefore, if clinical suspicion for injury exists after blunt thoracic trauma, a normal EFAST+CXR is insufficient to exclude injury and CT scan of the chest should be performed.

LEVEL OF EVIDENCE

Diagnostic tests/criteria, level III.