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Tran J, Haussner W, Shah K. Traumatic Pneumothorax: A Review of Current Diagnostic Practices And Evolving Management. J Emerg Med 2021; 61:517-528. [PMID: 34470716 DOI: 10.1016/j.jemermed.2021.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic). Traumatic PTX is a common pathology identified in the emergency department. Traditional management calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches. There is a paucity of cohesive literature on how to best manage the traumatic PTX. OBJECTIVE OF THE REVIEW This review aimed to describe current practices and future directions of traumatic PTX management. DISCUSSION Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic PTX. Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX. The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic PTX is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives. In patients with small or occult PTXs, even observation may be reasonable. CONCLUSIONS Modern management of the traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices (smaller catheters or observation). Ultimately, this shift is favorable in reducing length of stay, development of complications, and pain in the trauma patient.
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Affiliation(s)
- Jacqueline Tran
- Weill Cornell Medicine, Weill Cornell Medical College, New York, New York
| | - William Haussner
- Weill Cornell Medicine, Emergency Medicine, New-York Presbyterian Hospital, New York, New York
| | - Kaushal Shah
- Weill Cornell Medicine, Emergency Medicine, New-York Presbyterian Hospital, New York, New York
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Mao A, Rana HN, Brackett WJ, Figarola S, McQuiston S. Miraculous Recovery After Penetrating Trauma to the Mediastinum. Cureus 2020; 12:e11106. [PMID: 33240702 PMCID: PMC7682545 DOI: 10.7759/cureus.11106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Traumatic injury to the mediastinum can damage critical surrounding structures, including the pericardium, aorta, and bronchial tree. We highlight a miraculous case of a 13-year-old female with no past medical history who presented to the emergency department after being impaled in the chest by a metal fence post. After median sternotomy, the foreign object was removed, and the patient fortunately recovered with no permanent sequelae. The radiographic features of the injury are described, and potential unseen cardiovascular and respiratory complications are discussed.
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Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Surg 2020; 86:557-564. [PMID: 30629009 DOI: 10.1097/ta.0000000000002192] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma mechanisms. METHODS A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax, an immediate TT (TT placed before the initial chest CT), or if they were on mechanical ventilation. Size of PTX was quantified by measuring the radial distance between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging of the largest air pocket. Based on previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a delayed TT during the first week. A univariate analysis was performed to identify predictors of failure in both groups, and multivariate analysis was constructed to assess the independent impact of PTX measurement on the failure of observation while controlling for demographics and chest injuries. RESULTS Of the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those meeting inclusion criteria, 257 (89.0%) were successfully observed until discharge. Of those successfully observed, 247 (96%) patients had a measurement of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8% to predict successful observation. In the univariant analyses, rib fractures (p = 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or >35 mm) (P < 0.0001) were associated with failed observation. In multivariate analysis, PTX measuring 35 mm or less was an independent predictor of successful observation (odds ratio, 0.142; 95% confidence interval, 0.047-0.428)] for the combined blunt and penetrating trauma patients. CONCLUSION A 35-mm cutoff is safe as a general guide with only 9% of stable patients failing initial observation regardless of mechanism. LEVEL OF EVIDENCE Therapeutic, level III.
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Correa Restrepo J, Restrepo-Moreno M, Peláez LG, Díaz Cadavid RD, López-Vasco Y, Alejandra Rojas M, Mejía Toro DA, Morales Uribe CH. Radiografía de tórax de control en pacientes con neumotórax postraumático asintomático. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El trauma de tórax tiene alta incidencia y el neumotórax es el hallazgo más frecuente. La literatura es escasa sobre qué hacer con los pacientes asintomáticos y con neumotórax por trauma de tórax penetrante.
El objetivo de este estudio fue evaluar cuáles son los hallazgos de la radiografía de control de los pacientes con trauma de tórax penetrante que no son llevados inicialmente a cirugía, y su utilidad para determinar la necesidad de un tratamiento adicional.
Métodos. Se realizó un estudio retrospectivo de cohorte, incluyendo pacientes mayores de 15 años que ingresaron por trauma de tórax penetrante entre enero de 2015 y diciembre de 2017 y que no requirieron manejo quirúrgico inicial. Se analizaron los resultados de la radiografía de tórax, el tiempo de su toma y la conducta decidida según los hallazgos en los pacientes dejados inicialmente bajo observación.
Resultados. Se incluyeron 1.554 pacientes, cuya edad promedio fue de 30 años, 92,5 % del sexo masculino y 97% con herida por arma cortopunzante. Se dejaron 361 pacientes bajo observación con radiografía de control, de los cuales 186 (51,5 %) no presentaban alteraciones en su radiografía inicial, 142 tenían neumotórax menor del 30 % y 33 tenían neumotórax mayor del 30 %, hemoneumotórax o hemotórax. Se requirió toracostomía cerrada como conducta final en 78 casos, esternotomía o toracotomía en 2 casos y 281 se dieron de alta.
Conclusión. En pacientes asintomáticos con neumotórax pequeño o moderado y sin otras lesiones significativas, podrían ser innecesarios los largos tiempos de observación, las radiografías y la toracostomía cerrada.
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Hefny AF, Kunhivalappil FT, Paul M, Almansoori TM, Zoubeidi T, Abu-Zidan FM. Anatomical locations of air for rapid diagnosis of pneumothorax in blunt trauma patients. World J Emerg Surg 2019; 14:44. [PMID: 31497066 PMCID: PMC6720854 DOI: 10.1186/s13017-019-0263-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/22/2019] [Indexed: 12/22/2022] Open
Abstract
Background Bedside diagnostic ultrasound for traumatic pneumothorax is easy and reliable. However, the thoracic anatomical locations to be examined are debateable. We aimed to study the anatomical locations of blunt traumatic pneumothoraces as defined by chest CT scan to identify the areas that should be scanned while performing bedside diagnostic ultrasound. Methods This is a retrospective analysis of a data collected for a previous study in blunt trauma patients at our hospital during a 4-year-period with CT confirmed pneumothoraces. The anatomical distribution of the pneumothoraces and their volume were analyzed. Advanced statistical analysis was performed using repeated measures logistic regression models. Results Seven hundred three patients had a CT scan of the chest. Seventy-four patients (10.5%) were confirmed to have a pneumothorax. Only 64 were included in the study as they did not have a chest tube inserted before the CT scan. Twelve (18.8%) patients had bilateral pneumothorax. Seventy-six pneumothoraces were identified for which 41 patients had a right-sided pneumothorax and 35 patients had a left-sided pneumothorax. 95.1 % of the pneumothoraces detected on the right side were in the whole parasternal area with 75.6% seen in the lower parasternal region only. Similarly, 97.1 % of the pneumothoraces on the left side were seen in the whole parasternal area with 80% seen in the lower parasternal region only. Conclusions The current study showed that air pockets of blunt traumatic pneumothoraces are mainly located at the parasternal regions especially in pneumothorax with small volume. We recommend a quick ultrasound scanning of the parasternal regions on both sides of the chest from proximal to distal as the appropriate technique for the detection of pneumothoraces in blunt trauma setting.
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Affiliation(s)
- Ashraf F Hefny
- 1Trauma group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, P O Box 18532, Al-Ain, United Arab Emirates
| | | | - Manoj Paul
- Department of Radiology, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Taleb M Almansoori
- 3Department of Radiology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Taoufik Zoubeidi
- 4Department of Statistics, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Fikri M Abu-Zidan
- 1Trauma group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, P O Box 18532, Al-Ain, United Arab Emirates
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Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Surg 2019; 87:738. [PMID: 31045730 DOI: 10.1097/ta.0000000000002353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Walker SP, Barratt SL, Thompson J, Maskell NA. Conservative Management in Traumatic Pneumothoraces: An Observational Study. Chest 2017; 153:946-953. [PMID: 29080710 DOI: 10.1016/j.chest.2017.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Traumatic pneumothoraces are a common consequence of major trauma. Despite this, there is a paucity of literature regarding their optimal management, including the role of conservative treatment. The aim of this study was to assess the treatment, complications, and outcomes of traumatic pneumothoraces in patients presenting to a major trauma center. METHODS The prospectively collected Trauma Audit and Research Network (TARN) database was used to identify all patients presenting with traumatic pneumothoraces to a UK major trauma center from April 2012 to December 2016. Demographics, mechanism of injury, injury severity score (ISS), management, and outcomes were analyzed. RESULTS Six hundred two patients were included during the study period. Mean age was 48 years (SD, 22 years), and 73% were men. Mean ISS was 26 and inpatient mortality was 9%. Of the 602 traumatic pneumothoraces, 277 of 602 (46%) were initially treated conservatively. Two hundred fifty-two of 277 patients in this cohort (90%) did not require subsequent chest tube insertion, including the majority of patients (56 of 62 [90%]) who were receiving positive pressure ventilation (PPV) on admission. The hazard ratio (HR) for failure of conservative management showed no difference between the ventilated and nonventilated patients (HR, 1.1; P = .84). Only the presence of a large hemothorax was associated with an increased likelihood of failure of conservative management. CONCLUSIONS In the largest observational study of traumatic pneumothoraces published to date, > 90% of patients whose pneumothorax was managed conservatively never required subsequent tube drainage. Importantly, this also applies to patients requiring PPV, with no significant increased risk of failure of expectant management. These data support a role for conservative management in traumatic pneumothoraces.
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Affiliation(s)
- Steven P Walker
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
| | - Shaney L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
| | - Julian Thompson
- Intensive Care Unit, Southmead Hospital, Bristol, England; Severn Major Trauma Network, North Bristol NHS Trust, Bristol, England.
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
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Hefny AF, Kunhivalappil FT, Matev N, Avila NA, Bashir MO, Abu-Zidan FM. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore Med J 2017; 59:150-154. [PMID: 28741012 DOI: 10.11622/smedj.2017074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL.
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Affiliation(s)
- Ashraf F Hefny
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates.,Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Nikolay Matev
- Department of Radiology, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Norman A Avila
- Trauma Registry Program, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Masoud O Bashir
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
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