Cardiothoracic trauma

Age differences in blunt chest trauma: a cross-sectional study

Introduction

Trauma is the most common cause of presentation to hospital emergency services. After extremity and cranial injuries, blunt thoracic trauma is the third most common injury.

Aim

In this study, we aimed to present and assess blunt chest trauma in adults aged below 65 and elderly (age ≥ 65).

Material and methods

In this study, 130 patients (86 young (age 18-64) and 44 elderly (age ≥ 65)) who applied to the emergency department with blunt thoracic trauma between October 2017 and October 2019 were evaluated retrospectively.

Results

Of the patients, 99 (76.1%) were male, and 31 (23.9%) were female. The mean age was 54.41 ±20.13 years, and the patients were between 18 and 95 years of age. The most common cause of blunt thoracic trauma in the elderly group was a fall (n = 27; 61.3%), while in-vehicle traffic accident was most common in the young group (n = 43; 50%). "Flail chest," which is observed as a complication after multiple rib fractures, was present in 1 patient in the young group and in 10 patients in the elderly group; the difference was statistically significant (p > 0.05). Seven (5.3%) patients died. The mean hospital stay was 5.1 (1-60) days, which was borderline-significantly higher in the elderly group (p = 0.056).

Conclusions

Due to its life-threatening properties, the detection of blunt thorax trauma is a priority among multiple-trauma patients. For this reason, an aggressive diagnosis and treatment approach is essential in the whole patient group, especially among the elderly.

Thoracic Traumas: A Single-Center Experience

OBJECTIVES

Trauma is currently among the most important health problems resulting in mortality. Approximately 25% of trauma-related deaths are associated with thoracic trauma. In the present study, morbidity and mortality rates and interventions performed in patients who had been treated as inpatients in Dr. Siyami Ersek Thoracic and Cardiovascular Surgery hospital after trauma were aimed to be evaluated.

MATERIAL AND METHODS

In our study, 404 patients who were treated as inpatients because of thoracic trauma between January 2005 and December 2008 were retrospectively evaluated.

RESULTS

The rates of blunt and penetrating trauma were 39.6% and 60.4%, respectively. In the study, 115 (28.4%) patients were noted to have pneumothorax, 99 (24.5%) had hemothorax, and 57 (14.1%) had hemopneumothorax. While tube thoracostomy was sufficient for treatment in approximately 80% of the patients, major surgical interventions were performed in 12.6% of the patients. Mortality rate was found to be 2.2%.

CONCLUSION

In patients with chest trauma, necessary interventions should be started at the time of the event, and the time from trauma to arriving at the emergency department should be made the best of. Mortality and morbidity rates in thoracic trauma cases may be reduced by timely interventions and effective intensive care monitoring.

Chest injuries based on medical rescue team data

Injuries are the leading cause of death before the age of 40 years, and the third most common incidence of death worldwide after cardiovascular diseases and cancer. THE AIM OF THE STUDY was to determine the number and type of chest injuries, based on EMS (Emergency Medical Service) documentation in the district of Otwock, with particular emphasis on patient age and gender at the time of injury.

MATERIAL AND METHODS

Analysis considered data obtained from medical rescue teams of Otwock County in 2009 concerning chest injuries.

RESULTS

The study group comprised 166 cases of chest injuries. Chest injuries were more often diagnosed in male patients. Most accidents occurred in the afternoon (between 1 and 6pm), and in the summer and winter seasons. Motor vehicle accidents and falls from heights were the most common cause of chest injuries, while the largest number of cases involved superficial chest injuries.

CONCLUSIONS

Chest injuries accounted for 12% of all medical rescue team interventions, due to injuries, most often connected with superficial contusions of the chest wall. Rib fractures are usually caused by blunt chest injuries, most often relating to the V-VIII ribs. Fractures of the I-III ribs are rare and are evidence of a significant injury. Due to the flexibility of the thoracic wall, fractures in children are less common, as compared to the adult population. Most chest injuries occur in the afternoon during increased patient activity.

Simulation for trauma and combat casualty care

Training medical providers to care for traumatically injured patients is a difficult undertaking and currently used training strategies are often suboptimal. The further strains placed on trauma care in the military environment only add to the challenge. Simulation applications ranging from simple physical models to complex, computer-based virtual reality systems have either been developed or are being developed to help support and improve trauma care training. Several of these applications have been shown to be as good as or better than the standard training methods they are designed to replace. Simulators are available for training in the treatment of disorders of the airway, difficulty with breathing, and problems dealing with circulation as well as various non-life-threatening but disabling injuries. Some of these simulators have already drastically changed how the standard Advanced Trauma Life Support course is taught. Advances in both technology and application of simulators will continue to affect trauma skills training for the foreseeable future.

Rare but serious complications of central line insertion

Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

Surgical management of penetrating pulmonary injuries

Chest injuries were reported as early as 3000 BC in the Edwin Smith Surgical Papyrus. Ancient Greek chronicles reveal that they had anatomic knowledge of the thoracic structures. Even in the ancient world, most of the therapeutic modalities for chest wounds and traumatic pulmonary injuries were developed during wartime.

The majority of lung injuries can be managed non-operatively, but pulmonary injuries that require operative surgical intervention can be quite challenging. Recent progress in treating severe pulmonary injuries has relied on finding shorter and simpler lung-sparing techniques. The applicability of stapled pulmonary tractotomy was confirmed as a safe and valuable procedure.

Advancement in technology have revolutionized thoracic surgery and ushered in the era of video-assisted thoracoscopic surgery (VATS), providing an alternative method for accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries.

The aim of this article is to describe the incidence of the penetrating pulmonary injuries, the ultimate techniques used in its operative management, as well as the diagnosis, complications, and morbidity and mortality.

Penetrating cardiac injury

OBJECTIVES

To report a case of penetrating cardiac injury with patient's survival.

CLINICAL PRESENTATION AND INTERVENTION

A 23-year-old man stabbed with a knife to the epigastric area just below the right costal margin was brought to the Emergency Room, Al-Adan Hospital, Kuwait, in a state of shock. Aggressive resuscitation was performed, chest X-ray showed no evidence of hemo- or pneumothorax. Exploratory laparotomy was performed revealing a severely congested liver, with no intraperitoneal hemorrhage to explain his being in a state of shock. Left thoracotomy revealed pericardial tamponade with perforation in the right ventricle and hemorrhage. A mattress suture was used to control bleeding from the right ventricle. Postoperative echography revealed a tear in the interventricular septum and papillary muscle. Open-heart surgery was performed to repair the injured tissues. The patient made an uneventful recovery.

CONCLUSION

This report shows that patients with penetrating cardiac injuries and detectable vital signs on arrival at the hospital can be salvaged by prompt surgical intervention.

Outcome of major cardiac injuries at a Canadian trauma center

BACKGROUND

Canadian trauma units have relatively little experience with major cardiac trauma (disruption of a cardiac chamber) so injury outcome may not be comparable to that reported from other countries. We compared our outcomes to those of other centers.

METHODS

Records of patients suffering major cardiac trauma over a nine-year period were reviewed. Factors predictive of outcome were analyzed.

RESULTS

Twenty-seven patients (11 blunt and 16 penetrating) with major cardiac trauma were evaluated. Injury severity scores (ISS) were similar for blunt (49.6 +/- 16.6) and penetrating (39.5 +/- 21.6, p = 0.20) injuries. Five of 11 blunt trauma patients, and 9 of 16 penetrating trauma patients, had detectable vital signs on hospital arrival (p = 0.43). Ten patients underwent emergency department thoracotomy and 11 patients had cardiac repair in the operating theatre. Eleven patients survived and 16 died. Survivors had a lower ISS (33.7 +/-15.4) than non-survivors (50.4 +/- 20.4; p = 0.03). Two of 11 blunt trauma patients and 9 of 16 penetrating trauma patients survived (p = 0.06). Eleven of 14 patients with detectable vital signs survived; all 13 without detectable vital signs died (p = 0.00003). Ten of eleven patients treated in the operating theatre survived, while only one of the other 16 patients survived (p = 0.00002).

CONCLUSIONS

Patients with major cardiac injuries and detectable vital signs on hospital arrival can be salvaged by prompt surgical intervention in the operating theatre. Major cardiac injuries are infrequently encountered at our center but patient survival is comparable to that reported from trauma units in other countries.

Anatomical considerations in the surgical management of blunt thoracic aortic injury

PURPOSE

Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal.

METHODS

A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death.

RESULTS

In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained.

CONCLUSION

Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA.

Impact of Presenting Physiology and Associated Injuries on Outcome following Traumatic Rupture of the Thoracic Aorta

We hypothesized that the predominant factor influencing outcome of traumatic rupture of the thoracic aorta (TRA) was the degree of shock on presentation and associated injuries. We reviewed our experience with TRA over a 15-year period. Patients were classified as “unstable” if presenting systolic blood pressure was <90 mm Hg or if it decreased to <90 mm Hg after admission. We determined the presence of closed head injury, cardiac risk factors, a preoperative acute lung injury (ALI). The influence of these factors on mortality, postoperative adult respiratory distress syndrome (ARDS), and paralysis was analyzed. One hundred thirty-six patients were admitted with TRA. One hundred twenty underwent operative repair with a mortality of 31 per cent. Operative mortality was significantly higher in unstable patients (62%) versus stable patients (17%, P = 0.001), in patients with cardiac risk factors (71%) versus those without (24%, P = 0.001), and in patients with preoperative free rupture (83%) with versus those without (19%, P = 0.001). Free rupture was the cause of hypotension in only 10 of 42 unstable patients, with the remainder being due to other causes. Preoperative ALI was associated with a marked increase in postoperative ARDS (47% with vs 9% without, P = 0.001) but not operative mortality. Mechanical circulatory support (MCS) was used in 59 cases, none of whom experienced paralysis, whereas eight of 61 operated on without MCS developed paralysis ( P = 0.001). When logistic regression was applied the use of MCS was not determined to be statistically significant. However, preoperative instability was found to be a significant predictor of postoperative paralysis with the risk being increased 5.5 times (confidence interval 3.3–10). The predominant factor influencing mortality, postoperative ARDS, and paralysis was preoperative instability and associated injuries. In patients who are hypotensive, other injuries should take precedence over repair of TRA. Patients who are stable but who have cardiac or pulmonary risk factors may be better managed by a period of nonoperative management until their condition improves.

Penetrating Cardiac Trauma at an Urban Trauma Center: A 22-Year Perspective

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975–1985; 113 patients) and Period 2 (1986–1996; 79 patients) were by χ2 or Fisher's exact tests. Statistical significance was defined as P ≤ 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30–90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.