1
|
van Diepen MR, van Wijck SFM, Vittetoe E, Sauaia A, Wijffels MME, Pieracci FM. Surgical stabilization of rib fractures in anticoagulated patients: Proceed with caution? Injury 2024; 55:111708. [PMID: 38955570 DOI: 10.1016/j.injury.2024.111708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 05/27/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) is increasingly performed, however the outcome of patients undergoing SSRF while on pre-injury antithrombotic therapy remains unknown. We compared surgical variables and outcomes of patients who were and were not on antithrombotic therapy. We hypothesize pre-injury anticoagulation is associated with delay in SSRF and worse outcomes. METHODS For this retrospective cohort study, we queried the Chest Injury International Database, for patients undergoing SSRF between 08/2018 and 03/2022. Antithrombotic therapy was categorized into antiplatelet and anticoagulant use. Primary outcome was time from admission to SSRF. Secondary outcomes included SSRF duration and complications. Numerical data were presented as median (IQR), categorical data as number (%). Inverse probability weighting was used to control for confounding. RESULTS Two hundred and eighteen SSRF patients were included, 25 (11 %) were on antithrombotic therapy. These patients were older (72 years, (65-80) versus 57 years, (43-66); p < 0.001) with lower ISS (14, (10-20) versus 21, (14-30); p = 0.002). Time from admission to SSRF was comparable (2 days, (1-4) versus 2 days, (1-4); p = 0.37) as was operative time (154 mins, (120.0-212.0) versus 177 mins, (143.0-210.0); p = 0.34). Patients using antithrombotics had fewer ICU-free days (24 (22-26) versus 28 (23-28); p = 0.003) but more ventilator free days (28, (28-28) versus 27 (27-28); p < 0.008). After adjusting for confounding, pre-injury anticoagulation was not significantly associated with delayed SSRF (Relative Risk, RR=1.37, 95 % CI 0.30-6.24), operative time (RR=1.07, 95 % CI0.88-1.31), IFD <=28 (RR=2.05, 95 %CI:0.33-12.67), VFD<=27 (RR=0.71, 95 %CI:0.15-3.48) or complications (RR=0.55, 95 % CI0.06-5.01). CONCLUSION Pre-injury antithrombotic drug use neither delayed SSRF nor impacted operative time in patients requiring SSRF and was not associated with increased risk of complications. Our data suggest SSRF can be safely performed without delay in patients who use anticoagulation pre-injury. LEVEL OF EVIDENCE IV. STUDY TYPE Therapeutic/care management.
Collapse
Affiliation(s)
- Max R van Diepen
- Trauma Research Unit Department of surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado, United States.
| | - Suzanne F M van Wijck
- Trauma Research Unit Department of surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado, United States
| | - Emmalee Vittetoe
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado, United States
| | - Angela Sauaia
- Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado, United States
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Fredric M Pieracci
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado, United States
| |
Collapse
|
2
|
Doornkamp RN, van Winden DF, Buiten MS, Josephus Jitta D. Karate kick-induced myocardial contusion. BMJ Case Rep 2024; 17:e257082. [PMID: 38272515 PMCID: PMC10826487 DOI: 10.1136/bcr-2023-257082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 01/27/2024] Open
Abstract
Myocardial contusion should be suspected in a selected patient group with blunt thoracic trauma, who have elevated troponin, ECG changes and/or haemodynamical instability. Echocardiography is useful for direct visualisation of possible complications. In stable conditions, MRI allows for good visualisation of the heart and can confirm a suspected myocardial contusion as well as demonstrate the extent of myocardial damage. Based on the present literature, the authors developed a diagram for the diagnostic approach of a patient with suspected myocardial contusion.
Collapse
Affiliation(s)
- Ruben N Doornkamp
- Department of Emergency Medicine, Medisch Centrum Haaglanden Westeinde, Den Haag, Zuid-Holland, The Netherlands
| | - Daniëlle Fm van Winden
- Department of Emergency Medicine, Medisch Centrum Haaglanden Westeinde, Den Haag, Zuid-Holland, The Netherlands
| | - Maurits S Buiten
- Department of Cardiology, Medisch Centrum Haaglanden Westeinde, Den Haag, Zuid-Holland, The Netherlands
| | - Djike Josephus Jitta
- Department of Cardiology, Medisch Centrum Haaglanden Westeinde, Den Haag, Zuid-Holland, The Netherlands
| |
Collapse
|
3
|
Benhamed A, Batomen B, Boucher V, Yadav K, Mercier É, Isaac CJ, Bérubé M, Bernard F, Chauny JM, Moore L, Sirois MJ, Tazarourte K, Gossiome A, Émond M. Epidemiology, injury pattern and outcome of older trauma patients: A 15-year study of level-I trauma centers. PLoS One 2023; 18:e0280345. [PMID: 36716316 PMCID: PMC9886263 DOI: 10.1371/journal.pone.0280345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/26/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. METHODS A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes. RESULTS A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively). CONCLUSIONS Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.
Collapse
Affiliation(s)
- Axel Benhamed
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Brice Batomen
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Dalla Lana school of public health, University of Toronto, Toronto, Ontario, Canada
| | - Valérie Boucher
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Éric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Mélanie Bérubé
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Canada
| | - Jean- Marc Chauny
- Department of Emergency Medicine, Research Center, CIUSSS-Nord-de-l’Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, QC, Canada
| | - Marie Josée Sirois
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Karim Tazarourte
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Amaury Gossiome
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
| | - Marcel Émond
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
- * E-mail:
| |
Collapse
|
4
|
Heindel P, Ordoobadi A, El Moheb M, Serventi-Gleeson J, Garvey S, Heyman A, Patel N, Sanchez S, Kaafarani HMA, Herrera-Escobar J, Salim A, Nehra D. Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern. J Trauma Acute Care Surg 2022; 92:277-286. [PMID: 34739001 DOI: 10.1097/ta.0000000000003451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described. METHODS The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors. RESULTS We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures. CONCLUSION Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury. LEVEL OF EVIDENCE Prognostic/epidemiologic, level III.
Collapse
Affiliation(s)
- Patrick Heindel
- From the Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (P.H., A.O., M.E.M., A.S.), and Center for Surgery and Public Health (P.H., A.O., M.E.M., J.S.-G., S.G., A.H., N.P., J.H.E., A.S., D.N.), Brigham and Women's Hospital, Harvard Medical School; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (S.S.), Boston University School of Medicine, Boston, Massachusetts; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (H.M.A.K.), Massachusetts General Hospital, Harvard Medical School; and Division of Trauma, Burn and Critical Care Surgery, Department of Surgery (D.N.), University of Washington Medical Center, Seattle, Washington
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Turcato G, Zaboli A, Tenci A, Ricci G, Zannoni M, Scheurer C, Wieser A, Maccagnani A, Bonora A, Pfeifer N. Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients. EMERGENCY CARE JOURNAL 2021. [DOI: 10.4081/ecj.2021.10284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.
Collapse
|
6
|
Kay AB, Morris DS, Gardner S, Majercik S, White TW. Readmission for pleural space complications after chest wall injury: Who is at risk? J Trauma Acute Care Surg 2021; 91:981-987. [PMID: 34538827 DOI: 10.1097/ta.0000000000003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. METHODS Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. RESULTS Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. CONCLUSION We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level IV; Care management, Level V.
Collapse
Affiliation(s)
- Annika B Kay
- From the Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, Utah
| | | | | | | | | |
Collapse
|
7
|
Baker E, Battle C, Banjeri A, Carlton E, Dixon C, Ferry J, Hopkins P, Jones R, Murrells T, Norton C, Patient L, Rasheed A, Skene I, Tabner A, Tunnicliff M, Young L, Xyrichis A, Lee G. Prospective observational study to examine health-related quality of life and develop models to predict long-term patient-reported outcomes 6 months after hospital discharge with blunt thoracic injuries. BMJ Open 2021; 11:e049292. [PMID: 34244278 PMCID: PMC8268921 DOI: 10.1136/bmjopen-2021-049292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE This study aimed to examine the long-term outcomes and health-related quality of life in patients with blunt thoracic injuries over 6 months from hospital discharge and develop models to predict long-term patient-reported outcomes. DESIGN A prospective observational study using longitudinal survey design. SETTING The study recruitment was undertaken at 12 UK hospitals which represented diverse geographical locations and covered urban, suburban and rural areas across England and Wales. PARTICIPANTS 337 patients admitted to hospital with blunt thoracic injuries were recruited between June 2018-October 2020. METHODS Participants completed a bank of two quality of life surveys (Short Form-12 (SF-12) and EuroQol 5-Dimensions 5-Levels) and two pain questionnaires (Brief Pain Inventory and painDETECT Questionnaire) at four time points over the first 6 months after discharge from hospital. A total of 211 (63%) participants completed the outcomes data at 6 months after hospital discharge. OUTCOMES MEASURES Three outcomes were measured using pre-existing and validated patient-reported outcome measures. Outcomes included: Poor physical function (SF-12 Physical Component Score); chronic pain (Brief Pain Inventory Pain Severity Score); and neuropathic pain (painDETECT Questionnaire). RESULTS Despite a trend towards improving physical functional and pain at 6 months, outcomes did not return to participants perceived baseline level of function. At 6 months after hospital discharge, 37% (n=77) of participants reported poor physical function; 36.5% (n=77) reported a chronic pain state; and 22% (n=47) reported pain with a neuropathic component. Predictive models were developed for each outcome highlighting important data collection requirements for predicting long-term outcomes in this population. Model diagnostics including calibration and discrimination statistics suggested good model fit in this development cohort. CONCLUSIONS This study identified the recovery trajectories for patients with blunt thoracic injuries over the first 6 months after hospital discharge and present prognostic models for three important outcomes which after external validation could be used as clinical risk stratification scores.
Collapse
Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
- Emergency Department, King's College Hospital, London, UK
| | - Ceri Battle
- Welsh Institute of Biomedical and Emergency Medicine Research, Swansea Bay University Health Board, Port Talbot, Neath Port Talbot, UK
| | - Abhishek Banjeri
- Emergency Department, Buckingham Healthcare NHS Trust, Amersham, UK
| | - Edward Carlton
- Emergency Department, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Christine Dixon
- Emergency Department, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, UK
| | - Jennifer Ferry
- Department of Anesthetics, Aneurin Bevan Health Board, Newport, UK
| | - Philip Hopkins
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Robert Jones
- Emergency Department, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Lee Patient
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | - Ashraf Rasheed
- General Surgery, Aneurin Bevan Health Board, Newport, UK
| | - Imogen Skene
- Emergency Department, Barts Health NHS Trust, London, UK
| | - Andrew Tabner
- Emergency Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Malcolm Tunnicliff
- Emergency Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Louise Young
- Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Gerry Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| |
Collapse
|
8
|
Baker E, Xyrichis A, Norton C, Hopkins P, Lee G. Challenges associated with recovery from blunt thoracic injuries from hospital admission to six-months after discharge: A qualitative interview study. Int Emerg Nurs 2021; 57:101045. [PMID: 34243106 DOI: 10.1016/j.ienj.2021.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Recovery for patients presenting to trauma services globally with blunt thoracic injury (BTI) remains challenging with substantial levels of physical, psychological socio-economic burden. The aim of this study is to examine the challenges experienced by patients with BTI from hospital admission to 6-months after hospital discharge. METHODS Participants were recruited from trauma patients admitted with BTI and were recruited from 7 sites across England and Wales between March and June 2019. Semi-structured interviews were conducted at six-months after discharge from hospital, and in total 11 interviews were undertaken. Interviews were recorded, transcribed, and analysed with reflexive thematic analysis. RESULTS Two themes were identified within the data: (i) Challenges within the acute hospital admission where pain and analgesic management and the processes of investigation and treatment were the sources of most challenges to recovery. (ii) Challenges within the post-discharge recovery journey, where managing pain at home, unidentified injuries, and mental well-being impacted most on recovery. CONCLUSIONS This study adds to the body of qualitative evidence surrounding recovery from major trauma and the patient experience within the recovery journey after BTI and It is important that clinicians consider the whole recovery journey as a continuous process rather than two isolated processes.
Collapse
Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom; Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| |
Collapse
|
9
|
Mukerji S, Tan E, May C, Micanovic C, Blakemore P, Phelps K, Melville H, Jones P. Retrospective validation of a risk stratification tool developed for the management of patients with blunt chest trauma (the STUMBL score). Emerg Med Australas 2021; 33:841-847. [PMID: 33599054 DOI: 10.1111/1742-6723.13740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/11/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess validity of the STUMBL score in New Zealand for complications of blunt chest trauma without multi-trauma and immediate life-threatening injuries. METHODS A multi-centre, retrospective observational study was carried out in five EDs. Area under the receiver operating characteristic curve (AUROC) was calculated for all, early and late complications and ethnic sub-groups. Youden Index generated for each ROC was used to indicate cut scores for risks of complication, ICU admission, prolonged length of stay (LOS) and mortality. RESULTS A total of 445 patients were included. AUROC for all complications composite were (0.73, 95% confidence interval [CI] 0.68-0.77), mortality (0.92, 95% CI 0.89-0.94), ICU admissions (0.78, 95% CI 0.73-0.81) and prolonged LOS (0.80, 95% CI 0.76-0.83) were calculated. The score performed better in the New Zealand European (Pākehā) sub-group compared to Māori and Pasifika (AUROC [95% CI]: 0.80 [0.73-0.85], 0.69 [0.56-0.79], 0.66 [0.46-0.82], respectively). Patients with scores >12 were at risk of complications from blunt chest trauma, >15 at risk of prolonged LOS and >18 at risk of ICU admission and mortality. CONCLUSIONS The STUMBL score at a cut-off of <12 did not predict all complications sufficiently well to recommend for general use in our population. However, a score >15 predicted prolonged LOS and a score >18 predicted mortality sufficiently to be clinically useful for these outcomes. The score is more accurate in New Zealand Pākehā and needs to be used with caution in Māori and Pasifika populations. A larger prospective validation is required to further assess the score.
Collapse
Affiliation(s)
- Saptarshi Mukerji
- Emergency Department, Capital and Coast District Health Board, Wellington, New Zealand
| | - Eunicia Tan
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | - Charlotte May
- Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | | | - Paul Blakemore
- Emergency Department, Tauranga Hospital, Bay of Plenty, New Zealand
| | - Kelly Phelps
- Emergency Department, Whakatane Hospital, Whakatane, New Zealand
| | - Hannah Melville
- Emergency Department, Capital and Coast District Health Board, Wellington, New Zealand
| | - Peter Jones
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Emergency Department, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
10
|
Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma - an American Association for the Surgery of Trauma multi-institutional study. J Trauma Acute Care Surg 2020; 89:658-664. [PMID: 32773671 DOI: 10.1097/ta.0000000000002848] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures. METHODS This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. RESULTS Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS. CONCLUSION Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
Collapse
|
11
|
Martin CS, Lu N, Inouye DS, Nakagawa K, Ng K, Yu M, Hayashi MS. Delayed Respiratory Failure After Blunt Chest Trauma. Am Surg 2020; 87:1468-1473. [PMID: 33356435 DOI: 10.1177/0003134820966278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patient factors associated with delayed respiratory failure (DRF) after blunt chest trauma are not well documented. Earlier identification and closer monitoring may improve outcomes for these patients. The purpose of this study was to identify the prevalence and clinical predictors of DRF in patients after blunt chest trauma. MATERIALS AND METHODS A retrospective review of adult patients admitted to a Level 1 trauma center after blunt chest trauma between January 1, 2009 and December 31, 2013, was conducted. Patients with early respiratory failure were compared to patients with DRF using Fisher's exact tests, chi square, and Student's t-tests. A P-value of <.05 was considered significant. RESULTS 1299 patients had blunt chest trauma and at least 1 rib fracture, of which 830 met inclusion criteria. 5.8% of patients progressed to respiratory failure. Respiratory failure was delayed in 25% of these patients. DRF patients had significantly lower ISS (16.5 vs. 22.7, P = .04), more bilateral rib fractures (66.7% vs. 28.7%, P = .02) and fewer pulmonary contusions (16.7% vs. 50.0%, P = .04). DISCUSSION Injury patterns, including bilateral rib fractures without pulmonary contusions and low but severe Injury Severity Score burden, may help identify high-risk patients who may benefit from closer monitoring and more aggressive therapy.
Collapse
Affiliation(s)
| | - Ning Lu
- Department of Surgery, The Queen's Medical Center, HI, USA
| | - David S Inouye
- Department of Surgery, The Queen's Medical Center, HI, USA
| | | | - Karen Ng
- Department of Surgery, The Queen's Medical Center, HI, USA
| | - Mihae Yu
- Department of Surgery, The Queen's Medical Center, HI, USA
| | | |
Collapse
|
12
|
Battle C, O'Neill C, Toghill H, Newey L, Hutchings H. EarLy Exercise in blunt Chest wall Trauma: a feasibility trial (ELECT Trial). Emerg Med J 2020; 38:501-503. [PMID: 32878959 DOI: 10.1136/emermed-2020-209608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The aim was to complete a feasibility study that would test the methods of the main trial, that will investigate whether early thoracic and shoulder girdle exercises reduce chronic pain in patients with blunt chest wall trauma, when compared with normal care. METHODS A single centre, parallel, feasibility randomised controlled trial was completed at a University Teaching Hospital in Wales between June and September 2019. Adult patients with blunt chest wall trauma, admitted to hospital for greater than 24 hours, with no concurrent, immediately life-threatening injuries, were included. The intervention was a simple physiotherapy programme comprising thoracic and shoulder girdle exercises. Feasibility outcome measures included: primary outcomes: (1) 80% or more of identified eligible patients were approached for potential recruitment to the trial (2) 30% or less of approached, eligible patients dissented to participate in the trial; secondary outcomes: (3) follow-up data for patient secondary outcomes can be collected for 80% or more of patients, (4) there should be no greater than 10% increase in serious adverse events in the intervention group compared with the control group. RESULTS A total of 19/19 (100%) patients were deemed eligible for the trial and were approached for participation, 5/19 (26%) eligible patients declined to participate in the trial, follow-up data were collected for n=10/14 (71%) patients and there were no serious adverse events reported in either group. CONCLUSIONS We have demonstrated that a fully powered randomised clinical trial of the EarLy Exercise in blunt Chest wall Trauma Trial is feasible. TRIAL REGISTRATION NUMBER ISRCTN16197429.
Collapse
Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | | | - Hannah Toghill
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Luke Newey
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | | |
Collapse
|
13
|
Cone JT, Benjamin ER, Alfson DB, Biswas S, Demetriades D. The effect of body mass index on outcomes following severe blunt chest trauma. Injury 2020; 51:2076-2081. [PMID: 32646649 DOI: 10.1016/j.injury.2020.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/19/2020] [Accepted: 07/04/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Obesity has been described as a significant risk factor for adverse outcomes in hospitalized patients. However, recent literature reports an "obesity paradox", suggesting that obesity may have a protective effect in a subset of surgical and critically ill patients. The present study assesses the effect of body mass index (BMI) on outcomes following severe isolated blunt chest trauma. METHODS This was a TQIP database study including patients with severe isolated blunt chest injury (chest AIS 3-5, extrathoracic AIS <3). Patients were excluded for age <20 or >89, death on arrival, facility transfer, or BMI <10 or >55. Patients were divided into five groups according to BMI: underweight (BMI <18.5), normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9) and obesity class 3 (≥40.0). Logistic regression models were constructed to evaluate the effect of BMI on outcomes. RESULTS 28,820 patients met criteria for inclusion in the analysis. After multivariable analysis, underweight patients as well as obesity class 2 and 3 patients had a significantly higher mortality (OR 1.86 [95% CI, 1.12-3.10], OR 1.48 [95% CI, 1.02-2.16], and OR 1.60 [95% CI, 1.03-2.50]), respectively. Underweight patients had significantly higher risk of overall complications as compared to normal weight patients (OR 1.58 [95% CI, 1.34-1.88]). Obesity class 2 and 3 were independently associated with increased respiratory complications (OR 1.60 [95% CI, 1.27-2.01] and OR 1.58 [95% CI, 1.20-2.09], respectively) and all classes of overweight and obese patients were associated with increased risk of VTE complications (OR 1.68 [95% CI, 1.23-2.27], OR 1.98 [95% CI, 1.42-2.77], OR 2.32 [95% CI, 1.55-3.48], OR 2.02 [95% CI, 1.23-3.33], respectively for overweight and obesity class 1, 2, 3). CONCLUSIONS The obesity paradox does not extend to severe blunt chest trauma. Underweight and obesity class 2 and 3 patients have worse mortality than normal weight patients. Obesity was independently associated with an increased risk of pulmonary and VTE complications.
Collapse
Affiliation(s)
- Jennifer T Cone
- Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL, USA
| | - Elizabeth R Benjamin
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles 90033, CA, USA.
| | - Daniel B Alfson
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles 90033, CA, USA
| | - Subarna Biswas
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles 90033, CA, USA
| | - Demetrios Demetriades
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles 90033, CA, USA
| |
Collapse
|
14
|
Battle CE. Smoking status and outcomes in patients with rib fractures. Eur J Trauma Emerg Surg 2020; 46:935-936. [PMID: 31435699 DOI: 10.1007/s00068-019-01180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/26/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Ceri Elisabeth Battle
- Physiotherapy Department, Swansea Bay University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK.
| |
Collapse
|
15
|
van Aswegen H. Physiotherapy management of patients with trunk trauma: A state-of-the-art review. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2020; 76:1406. [PMID: 32671276 PMCID: PMC7343940 DOI: 10.4102/sajp.v76i1.1406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/27/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma. OBJECTIVES To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management. METHOD A non-systematic narrative review of published literature was performed. RESULTS Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice. CONCLUSION Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used. CLINICAL IMPLICATIONS Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.
Collapse
Affiliation(s)
- Helena van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
16
|
The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients. J Trauma Acute Care Surg 2020; 87:1260-1268. [PMID: 31425473 DOI: 10.1097/ta.0000000000002480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE Prognostic study, level II.
Collapse
|
17
|
Abstract
BACKGROUND There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. METHODS A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. RESULTS During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. CONCLUSION Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. LEVEL OF EVIDENCE Level IV, Prognostic and Epidemiologic.
Collapse
|
18
|
Aswegen HV, Reeve J, Beach L, Parker R, Olsèn MF. Physiotherapy management of patients with major chest trauma: Results from a global survey. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619850918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aim Major chest trauma is associated with significant morbidity and mortality. Management of patients with major chest trauma includes pain relief, ventilatory management, surgical fixation and early rehabilitation to improve both short- and long-term outcomes. Physiotherapy is widely considered an integral component of the multidisciplinary trauma team and aims to improve respiratory status and reduce the sequelae associated with immobility and reduced physical function. Despite this there is scarce evidence describing or investigating physiotherapy interventions and how these practices vary worldwide. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally. Methods A purpose designed online survey was administered to a group of experienced physiotherapists who work in the field of trauma. Results Response rate was 51% ( n = 49) and respondents represented all five continents. Respondents reported focussing on active coughing ( n = 46, 96%, r = 0.5, p = 0.98), body positioning ( n = 43, 94%, r = 0.7, p = 0.41), deep breathing exercises ( n = 44, 94%, r = 0.8, p = 0.66) and early mobilisation ( n = 47, 98%, r = 1, p = 0.64). Ambulation in hospital was reported to be common ( n = 46, 98%, r = 0.2, p = 0.99) but rehabilitation to address longer term sequelae following hospital discharge was reported to be rare ( n = 4, 8%). Conclusion This survey has highlighted those practices used by physiotherapists worldwide which aim to address the complications associated with major chest trauma. Having established global practice, the study provides a platform for future research investigating the efficacy of such interventions in improving both short- and long-term outcomes for patients following major chest injury.
Collapse
Affiliation(s)
- Heleen van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julie Reeve
- Department of Physiotherapy, Auckland University of Technology, Auckland, New Zealand
| | - Lisa Beach
- Department of Physiotherapy, The Royal Melbourne Hospital, Melbourne, Australia
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Monika Fagevik Olsèn
- Department of Physical Therapy, Sahlgrenska University Hospital and Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
19
|
Bauman ZM, Grams B, Yanala U, Shostrom V, Waibel B, Evans CH, Cemaj S, Schlitzkus LL. Rib fracture displacement worsens over time. Eur J Trauma Emerg Surg 2020; 47:1965-1970. [PMID: 32219487 PMCID: PMC7223740 DOI: 10.1007/s00068-020-01353-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/16/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time. METHODS Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002. RESULTS 78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002). CONCLUSION RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.
Collapse
Affiliation(s)
- Zachary Mitchel Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
| | - Benjamin Grams
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Ujwal Yanala
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Valerie Shostrom
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Brett Waibel
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Charity Hassie Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Samuel Cemaj
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Lisa Lynn Schlitzkus
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| |
Collapse
|
20
|
Van Lieshout EMM, Verhofstad MHJ, Van Silfhout DJT, Dubois EA. Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature. Eur J Trauma Emerg Surg 2020; 47:1259-1272. [PMID: 31982920 PMCID: PMC8321993 DOI: 10.1007/s00068-020-01305-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/14/2020] [Indexed: 11/25/2022]
Abstract
Purpose Myocardial contusion can be a life-threatening condition in patients who sustained blunt thoracic trauma. The diagnostic approach remains a subject of debate. The aim of this study was to determine the sensitivity and specificity of echocardiography, electrocardiography, troponins T and I (TnT and TnI), and creatine kinase muscle/brain (CK-MB) for identifying patients with a myocardial contusion following blunt thoracic trauma. Methods Sensitivity and specificity were first determined in a 10-year retrospective cohort study and second by a systematic literature review with meta-analysis. Results Of the 117 patients in the retrospective study, 44 (38%) were considered positive for myocardial contusion. Chest X-ray, chest CT scan, electrocardiograph, and echocardiography had poor sensitivity (< 15%) but good specificity (≥ 90%). Sensitivity to cardiac biomarkers measured at presentation ranged from 59% for TnT to 77% for hs-TnT, specificity ranged from 63% for CK-MB to 100% for TnT. The systematic literature review yielded 28 studies, with 14.5% out of 7242 patients reported as positive for myocardial contusion. The pooled sensitivity of electrocardiography, troponin I, and CK-MB was between 62 and 71%, versus only 45% for echocardiography and 38% for troponin T. The pooled specificity ranged from 63% for CK-MB to 85% for troponin T and 88% for echocardiography. Conclusion The best diagnostic approach for myocardial contusion is a combination of electrocardiography and measurement of cardiac biomarkers. If abnormalities are found, telemonitoring is necessary for the early detection of life-threatening arrhythmias. Chest X-ray and CT scan may show other thoracic injuries but provide no information on myocardial contusion. Electronic supplementary material The online version of this article (10.1007/s00068-020-01305-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dirk Jan T Van Silfhout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Simpson RB, Dorman JR, Hunt WJ, Edwards JG. Multiple rib fractures: A novel and prognostic CT-based classification system. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619895683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The accepted classification for multiple rib fractures is binary: flail chest or not. There is a wide spectrum of morphology with subsequent variation in the impact on chest wall mechanics and clinical outcomes. As the practice of surgical stabilisation of rib fractures evolves, there is a need for a better taxonomy. The aim of this study was to create a data-driven radiological classification system for multiple rib fractures, prognostic of both complications and surgical stabilisation of rib fracture. Methods The radiological pattern of injury was assessed for cases undergoing surgical stabilisation of rib fracture (n = 48) over a five-year period and a consecutive sample of non-operative controls (n = 48). Every rib fracture (n = 1032) was assessed on CT scans for location, displacement and comminution. An iterative classification system was developed and tested for inter-observer agreement and outcome prediction. Results The fractures occurred in a ‘series’ (≥3 consecutive ribs at a similar location) in 72% of cases: these were more likely to be displaced (p < 0.001). Variables included in the classification were the anatomical pattern (presence, length and overlap of series) and degree of displacement. The classification was prognostic for complications (p < 0.001), discriminated for fixation (C = 0.907) and had acceptable inter-observer agreement (k = 0.50). Conclusions The Sheffield Multiple Rib Fracture Classification derived categories of short/long series, and short/long flail chest, with sub-division according to the presence of displacement. It was prognostic for clinical outcomes and of surgical fixation. It may facilitate communication, comparison of outcomes and selection for management protocols.
Collapse
Affiliation(s)
- Rosalind B Simpson
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - Jessica R Dorman
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - William J Hunt
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| |
Collapse
|
22
|
Medar SS, Villacres S, Kaushik S, Eisenberg R, Stone ME. Pediatric Acute Respiratory Distress Syndrome (PARDS) in Children With Pulmonary Contusion. J Intensive Care Med 2019; 36:107-114. [PMID: 31711367 DOI: 10.1177/0885066619887666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE There is paucity of data about prevalence of pediatric acute respiratory distress syndrome (PARDS) in children with pulmonary contusion (PC). We intend to evaluate PC in children with chest trauma and the association between PC and PARDS. DESIGN Retrospective review of Institutional Trauma Registry for patients with trauma. SETTING Level 1 trauma center. PATIENTS Age 18 years and younger with a diagnosis of PC. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 1916 children with trauma, 50 (2.6%) had PC. Patients with PC and PARDS had lower Glasgow Coma Scale (GCS) score (7 [3-15] vs 15 [15-15], P = .0003), higher Injury Severity Scale (ISS) score (29 [22-34] vs 19 [14-22], P = .004), lower oxygen saturations (96 [93-99] days vs 99 [98-100] days, P = .0009), higher FiO2 (1 [1-1] vs 0.21 [0.21-0.40], P < .0001), lower oxygen saturation/FiO2 (S/F) ratios (97 [90-99] vs 457 [280-471], P < .0001), need for invasive mechanical ventilation (IMV; 86% vs 23%, P < .0001), and mortality (28% vs 0%, P = .006) compared to those without PARDS. Forty-two percent (21/50) of patients needed IMV, of these 61% (13/21) had PARDS. Patients who needed IMV had significantly lower GCS score (8 [3-11] vs 15 [15-15], P < .0001), higher ISS score (27 [22-34] vs 18 [14-22], P = .002), longer length of stay (LOS; 7.5 [4-14] days vs 3.3 [2-5] days, P = .003), longer hospital LOS (18 [7.0-25] vs 5 [4-11], P = .008), higher PARDS rate (62% vs 7%, P < .0001), and lower S/F ratios (99 [94-190] vs 461 [353-471], P < .0001) compared to those who did not require IMV. Lower GCS score was independently associated with both PARDS and need for IMV. CONCLUSIONS Pediatric ARDS in children with PC is independently associated with lower GCS score, and its presence significantly increased morbidity and mortality. Further larger studies are needed to explore association of lower GCS and higher injury score in children with PARDS and PC.
Collapse
Affiliation(s)
- Shivanand S Medar
- Division of Pediatric Critical Care Medicine and Pediatric Cardiology, 37292Children's Hospital at Montefiore, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
- Jacobi Medical Center, Bronx, NY, USA
| | - Sindy Villacres
- Division of Pediatric Critical Care Medicine, 25104Neumors Children's Hospital, Orlando, FL, USA
| | - Shubhi Kaushik
- Division of Pediatric Critical Care Medicine and Pediatric Cardiology, 37292Children's Hospital at Montefiore, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Melvin E Stone
- Albert Einstein College of Medicine, Bronx, NY, USA
- Jacobi Medical Center, Bronx, NY, USA
| |
Collapse
|
23
|
Battle C, Hutchings HA, Driscoll T, O’Neill C, Groves S, Watkins A, Lecky FE, Jones S, Gagg J, Body R, Abbott Z, Evans PA. A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial. BMJ Open 2019; 9:e029187. [PMID: 31350248 PMCID: PMC6661629 DOI: 10.1136/bmjopen-2019-029187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED. DESIGN Stepped wedge feasibility trial. SETTING Four EDs in England and Wales. PARTICIPANTS Adult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries. INTERVENTION A prognostic model (the STUMBL score) to guide clinical decision-making. OUTCOME MEASURES Primary: participant recruitment rate and clinicians' use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation. RESULTS Quantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible. DISCUSSION We have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial. TRIAL REGISTRATION NUMBER ISRCTN95571506; Post-results.
Collapse
Affiliation(s)
- Ceri Battle
- Emergency Department, Welsh Centre for Emergency Medicine Research, Swansea, UK
| | | | - Timothy Driscoll
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Claire O’Neill
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Sam Groves
- Swansea University College of Human and Health Sciences, Swansea, UK
| | - Alan Watkins
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Fiona Elizabeth Lecky
- Health Services Research, University of Sheffield, Sheffield, UK
- Emergency Department /TARN, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Sally Jones
- Emergency Department, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, UK
| | - James Gagg
- Emergency Department, Musgrove Park Hospital, Taunton, UK
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester
- Emergency Department, Manchester Royal Infirmary, Manchester, UK
| | - Zoe Abbott
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Phillip A Evans
- Emergency Department, Welsh Centre for Emergency Medicine Research, Swansea, UK
| |
Collapse
|
24
|
Störmann P, Becker N, Künnemeyer L, Wutzler S, Vollrath JT, Lustenberger T, Hildebrand F, Marzi I, Relja B. Contributing factors in the development of acute lung injury in a murine double hit model. Eur J Trauma Emerg Surg 2019; 46:21-30. [PMID: 30937460 DOI: 10.1007/s00068-019-01121-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Blunt chest (thoracic) trauma (TxT) is known to contribute to the development of secondary pulmonary complications. Of these, acute lung injury (ALI) is common especially in multiply injured patients and might not only be due to the direct trauma itself, but seems to be caused by ongoing and multifactorial inflammatory changes. Nevertheless, the exact mechanisms and contributing factors of the development of ALI following blunt chest trauma are still elusive. METHODS 60 CL57BL/6N mice sustained either blunt chest trauma combined with laparotomy without further interventions or a double hit (DH) including TxT and cecal ligation puncture (CLP) after 24 h to induce ALI. Animals were killed either 6 or 24 h after the second procedure. Pulmonary expression of inflammatory mediators cxcl1, cxcl5, IL-1β and IL-6, neutrophil infiltration and lung tissue damage using the Lung Injury Score (LIS) were determined. RESULTS Next to a moderate increase in other inflammatory mediators, a significant increase in CXCL1, neutrophil infiltration and lung injury was observed early after TxT, which returned to baseline levels after 24 h. DH induced significantly increased gene expression of cxcl1, cxcl5, IL-1β and IL-6 after 6 h, which was followed by the postponed significant increase in the protein expression after 24 h compared to controls. Neutrophil infiltration was significantly enhanced 24 h after DH compared to all other groups, and exerted a slight decline after 24 h. LIS has shown a significant increase after both 6 and 24 h compared to both control groups as well the late TxT group. CONCLUSION Early observed lung injury with moderate inflammatory changes after blunt chest trauma recovered quickly, and therefore, may be caused by mechanical lung injury. In contrast, lung injury in the ALI group did not undergo recovery and is closely associated with significant changes of inflammatory mediators. This model may be used for further examinations of contributing factors and therapeutic strategies to prevent ALI.
Collapse
Affiliation(s)
- Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - Nils Becker
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Leander Künnemeyer
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Department of Trauma, Hand and Orthopedic Surgery, Helios Horst Schmidt Clinic, Wiesbaden, Germany
| | - Jan Tilmann Vollrath
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | | | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| |
Collapse
|
25
|
Baker E, Xyrichis A, Norton C, Hopkins P, Lee G. The long-term outcomes and health-related quality of life of patients following blunt thoracic injury: a narrative literature review. Scand J Trauma Resusc Emerg Med 2018; 26:67. [PMID: 30119640 PMCID: PMC6098638 DOI: 10.1186/s13049-018-0535-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Major Trauma remains a leading cause of mortality and morbidity worldwide. Blunt Thoracic Injury (BTI) accounts for > 15% of United Kingdom (UK) trauma admissions and is consistently associated with respiratory related complications that include pneumonia and respiratory failure. Despite this, it is unclear in current clinical practice how BTI impacts on the recovering trauma patients after discharge from hospital. This study aimed to investigate the state of knowledge on the impact of BTI on the long-term outcomes and health-related quality of life (HRQoL). METHODS Data were sourced from Ovid MEDLINE, Ovid EMBASE, CINAHL and Science Direct using a pre-defined systematic search strategy. A subsequent hand search of key references was used to identify potentially missed studies. Abstracts were screened for eligibility and inclusion. Fifteen studies met the eligibility criteria and were critically appraised. Data were extracted, analysed and synthesised in categories and sub-categories following a narrative approach. RESULTS Three major themes were identified from the 15 studies included in this review: (i) physical impact of BTI, (ii) psychological impact of BTI and (iii) socio-economic impact of BTI. The bulk of the available data focused on the physical impact where further sub-themes included: (i) physical functioning, (ii) ongoing unresolved pain, (iii) reduced respiratory function, (iv) thoracic structural integrity. Although there was a substantial difference in the length and method of follow up, there remains a general trend towards physical symptoms improving over time, particularly over the first six months after injury. Despite this, where sequelae continued at six months it remained likely that these would also be present at two years after injury. CONCLUSION The literature review demonstrated that BTI is associated with substantial sequelae that impacts on all aspects of daily functioning. Despite this there remains a paucity of data relating to long term outcomes in the BTI population, especially relating to psychological and socio-economic impact. There is also little consensus on the measures, tools and time-frames used to measure outcomes and HRQoL in this population. The full impact of BTI on this population needs further exploration.
Collapse
Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. .,Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| |
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW To review the current use of continuous lateral rotational therapy (CLRT) in patients with thoracic injuries and its impact on clinical course, complications and outcome. RECENT FINDINGS Patient positioning is a key factor in the treatment of severe thoracic injuries and CLRT, and intermittent supine and prone position are basic options. There is a lack of randomized controlled studies for trauma patients with chest injury undergoing kinetic therapy as standard of care. A positive effect of kinetic therapy for prevention of secondary respiratory complications has been reported; nevertheless, no positive effect on mortality or length of hospital stay could be affirmed so far. In general, standardized therapeutic regimes for treatment of chest trauma have been implemented, including ventilator settings and positioning therapy. However, the available data do not allow a clear recommendation for rotational/kinetic therapy or prone positioning as superior or inferior. SUMMARY The benefit of changing the patients' position for secret mobilization and recruitment of atelectasis after chest trauma and therefore preventing secondary complications seems to be self-evident. Since only few studies report about the utility of CLRT in critically ill chest trauma patients, randomized controlled multicenter trials are necessary to analyze the overall benefit of such means.
Collapse
|
27
|
Laplace C, Harrois A, Hamada S, Duranteau J. Traumatismes thoraciques non chirurgicaux. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
28
|
Eghbalzadeh K, Sabashnikov A, Zeriouh M, Choi YH, Bunck AC, Mader N, Wahlers T. Blunt chest trauma: a clinical chameleon. Heart 2017; 104:719-724. [DOI: 10.1136/heartjnl-2017-312111] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/23/2017] [Accepted: 11/03/2017] [Indexed: 02/05/2023] Open
Abstract
The incidence of blunt chest trauma (BCT) is greater than 15% of all trauma admissions to the emergency departments worldwide and is the second leading cause of death after head injury in motor vehicle accidents. The mortality due to BCT is inhomogeneously described ranging from 9% to 60%. BCT is commonly caused by a sudden high-speed deceleration trauma to the anterior chest, leading to a compression of the thorax. All thoracic structures might be injured as a result of the trauma. Complex cardiac arrhythmia, heart murmurs, hypotension, angina-like chest pain, respiratory insufficiency or distention of the jugular veins may indicate potential cardiac injury. However, on admission to emergency departments symptoms might be missing or may not be clearly associated with the injury. Accurate diagnostics and early management in order to prevent serious complications and death are essential for patients suffering a BCT. Optimal initial diagnostics includes echocardiography or CT, Holter-monitor recordings, serial 12-lead electrocardiography and measurements of cardiac enzymes. Immediate diagnostics leading to the appropriate therapy is essential for saving a patient’s life. The key aspect of the entire management, including diagnostics and treatment of patients with BCT, remains an interdisciplinary team involving cardiologists, cardiothoracic surgeons, imaging radiologists and trauma specialists working in tandem.
Collapse
|
29
|
Kane ED, Jeremitsky E, Bittner KR, Kartiko S, Doben AR. Surgical Stabilization of Rib Fractures: A Single Institution Experience. J Am Coll Surg 2017; 226:961-966. [PMID: 29180034 DOI: 10.1016/j.jamcollsurg.2017.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Use of surgical stabilization of rib fractures (SSRF) has increased. Despite compelling small studies, many centers still struggle with determining criteria for intervention. We investigated the benefit of SSRF in our patients compared with nonoperative (NonOp) National Trauma Databank (NTDB) controls, specifically in the older population. STUDY DESIGN We performed a retrospective comparison of trauma patients with ≥3 and >5 rib fractures, who underwent SSRF at a tertiary care level I trauma center, with nonoperatively managed NTDB controls from equivalent level I centers between 2007 and 2014. The main outcomes measures included mortality, pneumonia, length of stay (LOS), ICU LOS, ventilator use, and tracheostomy rates. RESULTS Overall, SSRF patients were older, had a higher percentage of respiratory disease, and higher Injury Severity Scores (ISS). Despite more respiratory disease in SSRF patients vs NonOp (p < 0.0001), there was no difference in ventilator usage. Results of SSRF included decreases in mortality (12%, p = 0.008) and pneumonia (13%, p < 0.001) compared with NonOp on propensity score matching. On subgroup analysis of patients 65 years of age or older, ISS was higher in the SSRF group. Mortality was significantly lower for SSRF vs NonOp, even with higher frequency of respiratory disease within the group (p < 0.001). CONCLUSIONS Patients who underwent SSRF at our institution had improved outcomes despite a higher percentage of respiratory disease, compared with patients who were managed nonoperatively nationwide. Mortality rates improved for patients aged 65 and older, suggesting that this patient population may benefit more from SSRF.
Collapse
Affiliation(s)
- Erica D Kane
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA.
| | - Elan Jeremitsky
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Katharine R Bittner
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Susan Kartiko
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Andrew R Doben
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| |
Collapse
|
30
|
Störmann P, Lustenberger T, Relja B, Marzi I, Wutzler S. Role of biomarkers in acute traumatic lung injury. Injury 2017; 48:2400-2406. [PMID: 28888717 DOI: 10.1016/j.injury.2017.08.041] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/18/2017] [Accepted: 08/20/2017] [Indexed: 02/02/2023]
Abstract
In severely injured patients severe thoracic trauma is common and can significantly influence the outcome of these critically ill patients by increased rates of mainly pulmonary complications. Furthermore, patients who sustained thoracic trauma are at increased risk for Acute Lung Injury (ALI) or Adult Respiratory Distress Syndrome (ARDS). Therapeutic options are limited, basically consisting of prophylactic antibiotic therapy and changing patient's positions. It is known, that ALI and ARDS differ clinically and pathobiologically from ALI/ARDS caused by other reasons, but the exact pathology remains elusive. Due to that no reliable predictive or surveillance biomarkers could be established for clinical diagnosis and identification of patients at high risk for acute traumatic lung injury. Nevertheless, there are plenty of promising markers that need to be further elucidated in larger case numbers and multicenter studies. This article sums up the recent status of those promising clinical biomarkers.
Collapse
Affiliation(s)
- Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Germany.
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Germany
| |
Collapse
|
31
|
Battle C, Abbott Z, Hutchings HA, O’Neill C, Groves S, Watkins A, Lecky FE, Jones S, Gagg J, Body R, Evans PA. Protocol for a multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL trial. BMJ Open 2017; 7:e015972. [PMID: 28698337 PMCID: PMC5541613 DOI: 10.1136/bmjopen-2017-015972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/12/2017] [Accepted: 05/22/2017] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). A definitive randomised controlled trial (impact trial) is required to assess the clinical and cost effectiveness of the new model before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design. METHODS/ANALYSIS This feasibility trial is designed to test the methods of a multicentre, cluster-randomised (stepped- wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a 5-month period; in the initial period acting as the controls (normal care), and in the second period acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a 6-week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory). Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed. ETHICS AND DISSEMINATION Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Patient recruitment will commence in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings. TRIAL REGISTRATION NUMBER ISRCTN95571506; Pre-results.
Collapse
Affiliation(s)
- Ceri Battle
- Emergency Department, Welsh Institute of Biomedical and Emergency Medicine Research, Morriston Hospital, Swansea, UK
| | - Zoe Abbott
- Swansea University Medical School,Swansea University, Swansea, UK
| | | | - Claire O’Neill
- Swansea University Medical School,Swansea University, Swansea, UK
| | - Sam Groves
- College of Human and Health Sciences,Swansea University, Swansea, UK
| | - Alan Watkins
- Swansea University Medical School,Swansea University, Swansea, UK
| | - Fiona E Lecky
- School of Health and Related Research,Sheffield University. Salford Royal NHS Foundation Trust, Salford, UK
| | - Sally Jones
- Emergency Department, Royal Gwent Hospital, Newport, UK
| | - James Gagg
- Emergency Department, Musgrove Park Hospital, Taunton, UK
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Manchester, UK
| | - Philip A Evans
- Emergency Department, Welsh Institute of Biomedical and Emergency Medicine Research, Morriston Hospital, Swansea, UK
| |
Collapse
|
32
|
Abstract
INTRODUCTION It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. METHODS Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007-2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. RESULTS There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. CONCLUSION The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. LEVEL OF EVIDENCE Therapeutic study, level IV.
Collapse
|
33
|
Factors Associated with ICU Admission following Blunt Chest Trauma. Can Respir J 2016; 2016:3257846. [PMID: 28044070 PMCID: PMC5156815 DOI: 10.1155/2016/3257846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/10/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Blunt chest wall trauma accounts for over 10% of all trauma patients presenting to emergency departments worldwide. When the injury is not as severe, deciding which blunt chest wall trauma patients require a higher level of clinical input can be difficult. We hypothesized that patient factors, injury patterns, analgesia, postural condition, and positive airway pressure influence outcomes. Methods. The study population consisted of patients hospitalized with at least 3 rib fractures (RF) and at least one pulmonary contusion and/or at least one pneumothorax lower than 2 cm. Results. A total of 140 patients were retrospectively analyzed. Ten patients (7.1%) were admitted to intensive care unit (ICU) within the first 72 hours, because of deterioration of the clinical conditions and gas exchange with worsening of chest X-ray/thoracic ultrasound/chest computed tomography. On univariable analysis and multivariable analysis, obliged orthopnea (p = 0.0018) and the severity of trauma score (p < 0.0002) were associated with admission to ICU. Conclusions. Obliged orthopnea was an independent predictor of ICU admission among patients incurring non-life-threatening blunt chest wall trauma. The main therapeutic approach associated with improved outcome is the prevention of pulmonary infections due to reduced tidal volume, namely, upright postural condition and positive airway pressure.
Collapse
|
34
|
Abstract
Introduction Blunt chest wall trauma is commonly recognised as a significant source of acute pain following injury but the longer term outcomes in this patient cohort are less well described. The aim of this pilot study was to investigate the incidence of chronic pain in patients with isolated blunt chest wall trauma, with or without rib fractures. Methods A short survey was completed over the phone, or as a postal survey. The emergency department medical records and hospital database were used to obtain the demographic data, including patient age, pre-existing conditions, trauma sustained, hospital and intensive care unit length of stay, mechanical ventilation days and mortality. Patients’ demographics were analysed using descriptive statistics and Mann–Whitney U and Fisher’s exact tests for comparison of variables. Results A total of 100 patients were admitted to hospital with isolated blunt chest wall trauma in 2014, with 67 patients eligible for inclusion in the study; 40 patients responded to the survey (60% response rate). Chronic pain was reported in 14 (35%) patients with a median pain severity score of 6 out of 10 (IQR: 3–7). The only significant predictor of chronic pain was if the patient’s mechanism of injury was an assault. Discussion The results of this pilot study have demonstrated that a high percentage of isolated blunt chest wall trauma patients suffer chronic pain at six months or more post-injury. Assault was the only predictor of chronic pain. Further prospective studies are required to evaluate the long-term outcomes following blunt chest wall trauma.
Collapse
Affiliation(s)
- Ceri E Battle
- Physiotherapy Department, NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
| | - Katie Young
- Physiotherapy Department, NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
| | - Phillip A Evans
- Physiotherapy Department, NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
| |
Collapse
|
35
|
Abstract
Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
Collapse
|
36
|
Characteristics of chest wall injuries that predict postrecovery pulmonary symptoms. J Trauma Acute Care Surg 2015. [DOI: 10.1097/ta.0000000000000718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
37
|
Ho VP, Madbak F, Horng H, Sifri ZC, Mohr AM. Analysis of Hypoxemia in Early Ventilator-Associated Pneumonia Secondary to Haemophilus in Trauma Patients. Surg Infect (Larchmt) 2015; 16:293-7. [PMID: 25894664 DOI: 10.1089/sur.2013.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Haemophilus species bacteria (HSB) are known pathogens responsible for early pneumonia in intubated trauma patients. The primary goal of this study was to examine the incidence and extent of hypoxemia in intubated trauma patients who develop early ventilator-associated pneumonia (VAP) secondary to HSB. On the basis of our clinical experiences, we hypothesized that patients with Haemophilus species bacteria pneumonia (HSBP) would have a high rate of hypoxemia but that the effect would be transient. METHODS Retrospective review of intubated trauma patients from an urban level I trauma center with HSBP diagnosed by deep tracheal aspirate or bronchoalveolar lavage from April 2007 to November 2012. Collected variables included day of HSBP diagnosis; PaO2 to FIO2 ratio (P:F) at HSBP diagnosis as well as HSBP day three and HSBP day seven; injury severity score (ISS) and its component parts; admission Glasgow Coma Scale (GCS) score; and mortality. Hypoxemia was defined as P:F <200. χ(2) Tests were utilized to assess factors that differed between hypoxemic and non-hypoxemic patients; data are presented as median (interquartile range, IQR). RESULTS Sixty-nine patients were identified (80% male; age, 35 y [range, 24-49]; ISS 27 [9-59]). Diagnosis of HSBP occurred early (hospital day 4 [range, 3-5]). Forty-three percent of patients had acute respiratory distress syndrome (ARDS) on HSBP day 1; this decreased to 26% on day three and to 30% on day seven. Forty patients (77%) had a tracheostomy performed. Patients with hypoxemia were significantly less likely to have a severe head injury (GCS<9), p<0.05. Patients with hypoxemia had similar hospital length of stay and mortality to patients who did not develop hypoxemia. CONCLUSION Haemophilus species bacteria pneumonia in trauma patients is associated with high rates of transient hypoxemia and a high tracheostomy rate, although subsequent outcomes are not affected. Patients with head injuries had a lower incidence of hypoxemia from pneumonia.
Collapse
Affiliation(s)
- Vanessa P Ho
- 1Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York
| | - Firas Madbak
- 2Department of Surgery, University of Pennsylvania Reading Health System, Reading, Pennsylvania
| | - Helen Horng
- 3Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- 3Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Alicia M Mohr
- 4Department of Surgery, University of Florida, Gainesville, Florida
| |
Collapse
|
38
|
Battle C, Hutchings H, Lovett S, Bouamra O, Jones S, Sen A, Gagg J, Robinson D, Hartford-Beynon J, Williams J, Evans A. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R98. [PMID: 24887537 PMCID: PMC4095687 DOI: 10.1186/cc13873] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 05/01/2014] [Indexed: 11/30/2022]
Abstract
Introduction Blunt chest wall trauma accounts for over 15% of all trauma admissions to Emergency Departments worldwide. Reported mortality rates vary between 4 and 60%. Management of this patient group is challenging as a result of the delayed on-set of complications. The aim of this study was to develop and validate a prognostic model that can be used to assist in the management of blunt chest wall trauma. Methods There were two distinct phases to the overall study; the development and the validation phases. In the first study phase, the prognostic model was developed through the retrospective analysis of all blunt chest wall trauma patients (n = 274) presenting to the Emergency Department of a regional trauma centre in Wales (2009 to 2011). Multivariable logistic regression was used to develop the model and identify the significant predictors for the development of complications. The model’s accuracy and predictive capabilities were assessed. In the second study phase, external validation of the model was completed in a multi-centre prospective study (n = 237) in 2012. The model’s accuracy and predictive capabilities were re-assessed for the validation sample. A risk score was developed for use in the clinical setting. Results Significant predictors of the development of complications were age, number of rib fractures, chronic lung disease, use of pre-injury anticoagulants and oxygen saturation levels. The final model demonstrated an excellent c-index of 0.96 (95% confidence intervals: 0.93 to 0.98). Conclusions In our two phase study, we have developed and validated a prognostic model that can be used to assist in the management of blunt chest wall trauma patients. The final risk score provides the clinician with the probability of the development of complications for each individual patient.
Collapse
|
39
|
Battle C, Hutchings H, Bouamra O, Evans PA. The effect of pre-injury anti-platelet therapy on the development of complications in isolated blunt chest wall trauma: a retrospective study. PLoS One 2014; 9:e91284. [PMID: 24609084 PMCID: PMC3946689 DOI: 10.1371/journal.pone.0091284] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 02/11/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction The difficulties in the management of the blunt chest wall trauma patient in the Emergency Department due to the development of late complications are well recognised in the literature. Pre-injury anti-platelet therapy has been previously investigated as a risk factor for poor outcomes following traumatic head injury, but not in the blunt chest wall trauma patient cohort. The aim of this study was to investigate pre-injury anti-platelet therapy as a risk factor for the development of complications in the recovery phase following blunt chest wall trauma. Methods A retrospective study was completed in which the medical notes were analysed of all blunt chest wall trauma patients presenting to a large trauma centre in Wales in 2012 and 2013. Using univariate and multivariable logistic regression analysis, pre-injury platelet therapy was investigated as a risk factor for the development of complications following blunt chest wall trauma. Previously identified risk factors were included in the analysis to address the influence of confounding. Results A total of 1303 isolated blunt chest wall trauma patients presented to the ED in Morriston Hospital in 2012 and 2013 with complications recorded in 144 patients (11%). On multi-variable analysis, pre-injury anti-platelet therapy was found to be a significant risk factor for the development of complications following isolated blunt chest wall trauma (odds ratio: 16.9; 95% confidence intervals: 8.2–35.2). As in previous studies patient age, number of rib fractures, chronic lung disease and pre-injury anti-coagulant use were also found to be significant risk factors. Conclusions Pre-injury anti-platelet therapy is being increasingly used as a first line treatment for a number of conditions and there is a concurrent increase in trauma in the elderly population. Pre-injury anti-platelet therapy should be considered as a risk factor for the development of complications by clinicians managing blunt chest wall trauma.
Collapse
Affiliation(s)
- Ceri Battle
- NISCHR Haemostasis Biomedical Research Unit. Morriston Hospital, Swansea, United Kingdom
- * E-mail:
| | - Hayley Hutchings
- College of Medicine, Swansea University, Swansea, United Kingdom
| | - Omar Bouamra
- Trauma Audit and Research Network, University of Manchester, Manchester, United Kingdom
| | - Phillip A. Evans
- NISCHR Haemostasis Biomedical Research Unit. Morriston Hospital, Swansea, United Kingdom
| |
Collapse
|