Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma

INTRODUCTION

Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults.

METHODS

Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management.

RESULTS

Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation.

CONCLUSION

Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

A selective non-operative approach to thoracic stab wounds is safe and cost effective - a South African experience

INTRODUCTION

Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma.

MATERIALS AND METHODS

The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms.

RESULTS

Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310).

DISCUSSION

Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms.

CONCLUSION

Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.

Critical Decisions in the Management of Thoracic Trauma

Traumatic injuries to the thorax are common after both blunt and penetrating trauma. Emergency medicine physicians must be able to manage the initial resuscitation and diagnostic workup of these patients. This involves familiarity with a range of radiologic investigations and invasive bedside procedures, including resuscitative thoracotomy. This knowledge is critical to allow for rapid decision making when life-threatening injuries are encountered. This article explores the initial resuscitation and assessment of patients after thoracic trauma, discusses available imaging modalities, reviews frequently performed procedures, and provides an overview of the indications for operative intervention, while emphasizing the critical decision making throughout.