Echocardiography in the evaluation of thoracic trauma

[Predictors of outcome in blunt chest trauma]

INTRODUCTION

Thoracic trauma is often associated with polytrauma. Because mortality is high, the search for prognostic tools is useful.

PATIENTS AND METHODS

A total of 108 patients with blunt thoracic trauma, 73 of whom had multiple injuries, were studied in an intensive care unit (ICU). The variables named as potential predictors of outcome were the need for mechanical ventilation, duration of ventilation, and high positive end-expiratory pressure (PEEP); the presence of rib fractures, pulmonary contusion, pleural involvement (hemo- and/or pneumothorax), or lung infection; the need for emergency surgery; mean duration of ICU stay, and age. We also studied whether or not the mortality rate was higher in polytrauma patients. Student t and chi2 tests (95% confidence level) and multiple regression analysis (Hosmer-Lemeshow goodness of fit) were used to analyze the results.

RESULTS

The need for mechanical ventilation, radiographic evidence of pulmonary contusion, emergency surgery, and hemodynamic instability were risk factors for increased mortality. Higher risk of mortality was not demonstrated for patients with multiple injuries. For patients in need of mechanical ventilation, high PEEP was a predictor of poor prognosis.

CONCLUSIONS

The presence of the aforementioned predictors (mechanical ventilation, high PEEP, pulmonary contusion, emergency surgery, and hemodynamic instability) indicate serious injury to the lung parenchyma, which is the main determinant of outcome for patients with thoracic trauma.

Systemic air embolism after intercostal chest drain insertion and positive pressure ventilation in chest trauma

Systemic air embolism is a potentially lethal often unrecognised complication of severe chest trauma. We present a case of delayed diagnosis of cerebral air embolism in a patient with severe thoracic trauma. The initiation of positive pressure ventilation, systemic hypotension, intraparenchymal chest drains and aerial transfer to an intensive care unit were all factors contributing to the development of systemic air embolism. The common clinical features, diagnostic tests and management of systemic air emboli are discussed.

Aortic transection

BACKGROUND

Traumatic aortic transection is uncommon in those trauma patients reaching hospital alive.

METHODS

The Victorian Major Trauma Study (VMTS) received data from 25 hospitals in Victoria, a State of 4.4 million people, and identified 1874 patients with blunt trauma and Injury Severity Score (ISS) greater than 15 over a 2-year period (1 March 1992-28 February 1993 and 1 May 1994-30 April 1995). The Federal Office of Road Safety (FORS) examined coronial data from 1 January 1992 to 31 December 1992. These studies allowed a retrospective, population-based review of experience with aortic transection.

RESULTS

The VMTS identified 19 patients who reached hospital, with signs of life at the scene of the accident, during a 2-year period. Of these, 8 left hospital alive: 4 without disability and 4 with disability related to non-thoracic injury. The annual incidence of aortic transection for the State, based on FORS data, was 13 per 1000000, lower than other reported studies. Review of the management of patients in hospital confirmed the usefulness of initial chest X-ray in diagnosis and the high incidence of associated injury.

CONCLUSIONS

The study raises a number of issues, including the question of direct referral of patients with severe chest injury to hospitals with cardiothoracic facilities, increased use of transoesophageal echocardiography in diagnosis and increased use of immediate laparotomy and thoracotomy in certain patients.

Echocardiography in thoracic trauma

The availability of bedside ultrasonography can dramatically impact the care of patients with cardiac or aortic injuries. A focused, limited echocardiographic examination in the initial evaluation of victims with thoracic injuries can provide vital information the clinician needs to expedite the management of these patients. This article reviews the current use of transthoracic and transesophageal echocardiography in patients with thoracic trauma.

[Contusio cordis--too seldom diagnosed?]

BACKGROUND

Myocardial contusion is the most common injury caused by blunt chest trauma. Cardiac contusion often does not produce significant symptoms and, thus, remains unrecognized.

CASE REPORT

A 29-year-old professional ice-hockey player presented with a tachyarrhythmia two days after having suffered a thoracic trauma. Two weeks prior to admission he had an influenza-like infection. Non-invasive diagnostic methods were normal. However, cardiac catheterization revealed an akinesis of the left ventricular anterior wall in the absence of any coronary artery lesions. Endomyocardial biopsy did not show any evidence of myocarditis but erythrocyte extravasations in the endo- and myocardium, thus, confirming the diagnosis of cardiac contusion. Three months later, left ventriculography and coronary angiography did neither demonstrate any abnormalities of ventricular contraction nor of the coronary vessels.

CONCLUSION

Myocardial contusion is still being rarely diagnosed after sporting accidents. Cardiac contusion is a benign disorder in most patients. However, due to its potentially lethal outcome and as sequelae may present late after the trauma, early and precise diagnosis is important, both from the clinical point of view as well as for future insurance requests. Thus, invasive diagnostic techniques should be performed when non-invasive examinations do not provide a conclusive diagnosis.