Flail chest and pulmonary contusion

Consideration of the thoracic phenotype of cerebro-costo-mandibular syndrome

Cerebro-costo-mandibular syndrome (CCMS) is a congenital condition with skeletal and orofacial abnormalities that often results in respiratory distress in neonates. The three main phenotypes in the thorax are posterior rib gaps, abnormal costovertebral articulation and absent ribs. Although the condition can be lethal, accurate diagnosis, and subsequent management help improve the survival rate. Mutations in the causative gene SNRPB have been identified, however, the mechanism whereby the skeletal phenotypes affect respiratory function is not well-studied due to the multiple skeletal phenotypes, lack of anatomy-based studies into the condition and rarity of CCMS cases. This review aims to clarify the extent to which the three main skeletal phenotypes in the thorax contribute to respiratory distress in neonates with CCMS. Despite the posterior rib gaps being unique to this condition and visually striking on radiographic images, anatomical consideration, and meta-analyses suggested that they might not be the significant factor in causing respiratory distress in neonates. Rather, the increase in chest wall compliance due to the rib gaps and the decrease in compliance at the costovertebral complex was considered to result in an equilibrium, minimizing the impact of these abnormalities. The absence of floating ribs is likely insignificant as seen in the general population; however, a further absence of ribs or vestigial rib formation is associated with respiratory distress and increased lethality. Based on these, we propose to evaluate the number of absent or vestigial ribs as a priority indicator to develop a personalized treatment plan based on the phenotypes exhibited.

Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review

Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.

Novel nomogram for predicting paradoxical chest wall movement in patients with flail segment of traumatic rib fracture: a retrospective cohort study

Flail chest is a severe injury to the chest wall and is related to adverse outcomes. A flail chest is classified as the physiologic, paradoxical motion of a chest wall or flail segment of rib fracture (RFX). We hypothesized that patients with paradoxical chest wall movement would present different clinical features from patients with a flail segment. This retrospective observational study included patients with blunt chest trauma who visited our level 1 trauma center between January 2019 and October 2022 and were diagnosed with one or more flail segments by computed tomography. The primary outcome of our study was a clinically diagnosed visible, paradoxical chest wall motion. We used the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting. After a feature selection using the LASSO regression model, we constructed a multivariable logistic regression (MLR) model and nomogram. A total of five risk factors were selected in the LASSO model and applied to the multivariable logistic regression model. Of these, four risk factors were statistically significant: the total number of RFX (adjusted OR [aOR], 1.28; 95% confidence interval [CI], 1.09-1.49; p = 0.002), number of segmental RFX including Grade III fractures (aOR, 1.78; 95% CI, 1.14-2.79; p = 0.012), laterally located primary fracture lines (aOR, 4.00; 95% CI, 1.69-9.43; p = 0.002), and anterior-lateral flail segments (aOR, 4.20; 95% CI, 1.60-10.99; p = 0.004). We constructed a nomogram to predict the personalized probability of the flail motion. A novel nomogram was developed in patients with flail segments of traumatic RFX to predict paradoxical chest wall motion. The number of RFX, Grade III segmental RFX, and the location of the RFX were significant risk factors.

Novel nomogram for predicting pulmonary complications in patients with blunt chest trauma with rib fractures: a retrospective cohort study

The direct consequences of chest trauma may cause adverse outcomes. Therefore, the early detection of high-risk patients and appropriate interventions can improve patient outcomes. This study aimed to investigate the risk factor for overall pulmonary complications in patients with blunt traumatic rib fractures. Prospectively recorded data of patients with blunt chest trauma in a level 1 trauma center between January 2019 and October 2022 were retrospectively analyzed. The primary outcomes were one or more pulmonary complications. To minimize the overfitting of the prediction model, we used the least absolute shrinkage and selection operator (LASSO) logistic regression. We input selected features using LASSO regression into the multivariable logistic regression model (MLR). We also constructed a nomogram to calculate approximate individual probability. Altogether, 542 patients were included. The LASSO regression model identified age, injury severity score (ISS), and flail motion of the chest wall as significant risk factors. In the MLR analysis, age (adjusted OR [aOR] 1.06; 95% confidence interval [CI] 1.03-1.08; p < 0.001), ISS (aOR 1.10; 95% CI 1.05-1.16; p < 0.001), and flail motion (aOR 8.82; 95% CI 4.13-18.83; p < 0.001) were significant. An MLR-based nomogram predicted the individual risk, and the area under the receiver operating characteristic curve was 0.826. We suggest a novel nomogram with good performance for predicting adverse pulmonary outcomes. The flail motion of the chest wall may be the most significant risk factor for pulmonary complications.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

BACKGROUND

Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.

METHODS

Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.

RESULTS

Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.

CONCLUSION

We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

[Pathophysiology, Diagnostics and Therapy of Pulmonary Contusion - Recommendations of the Interdisciplinary Group on Thoracic Trauma of the Section NIS of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT)]

Pulmonary contusion usually occurs in combination with other injuries and is indicative of a high level of force. Especially in multiply injured patients, pulmonary contusions are frequently detected. The injury is characterised by dynamic development, which might result in difficulties in recognising the actual extent of the injury at an early stage. Subsequently, correct classification of the extent of injury and appropriate initiation of therapeutic steps are essential to achieve the best possible outcome. The main goal of all therapeutic measures is to preserve lung function as best as possible and to avoid associated complications such as the development of pneumonia or Acute Respiratory Distress Syndrome (ARDS).The present report from the interdisciplinary working group "Chest Trauma" of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT) includes an extensive literature review on the background, diagnosis and treatment of pulmonary contusion. Without exception, papers with a low level of evidence were included due to the lack of studies with large cohorts of patients or randomised controlled studies. Thus, the recommendations given in the present article correspond to a consensus of the aforementioned interdisciplinary working group.Computed tomography (CT) of the chest is recommended for initial diagnosis; the extent of pulmonary contusion correlates with the incidence and severity of complications. A conventional chest X-ray may initially underestimate the injury, but is useful during short-term follow-up.Therapy for pulmonary contusion is multimodal and symptom-based. In particular, intensive care therapy with lung-protective ventilation and patient positioning are key factors of treatment. In addition to invasive ventilation, non-invasive ventilation should be considered if the patient's comorbidities and compliance allows this. Furthermore, depending on the extent of the lung injury and the general patient's condition, ECMO therapy may be considered as an ultima ratio. In particular, this should only be performed at specialised hospitals, which is why patient assignment or anticipation of early transfer of the patient should be anticipated at an early time during the course.

Blunt Chest Trauma in Polytraumatized Patients: Predictive Factors for Urgent Thoracotomy

Purpose: Current guidelines on urgent thoracotomy of polytraumatized patients are based on data from perforating chest injuries. We aimed to identify predictive factors for urgent thoracotomy after chest-tube placement for blunt chest trauma in a civilian setting. Methods: Polytraumatized patients (Injury Severity Score ≥16) with blunt chest trauma, submitted to a level I trauma centre during a period of 12 years that received at least one chest tube were included. Trauma mechanism, chest-tube output, haemoglobin values, need for cellular blood products, coagulopathies, rib fracture pattern, thoracotomy, and mortality were retrospectively analysed. Results: 235 polytraumatized patients were included. Patients that received urgent thoracotomy (UT, n = 10) showed a higher mean chest-tube output within 24 h with a median (Mdn) of 3865 (IQR 2423–5156) mL compared to the group with no additional thoracic surgery (NT, n = 225) with Mdn 185 (IQR 50–463) mL (p < 0.001). The cut-off 24-h chest-tube output value for recommended thoracotomy was 1270 mL (ROC-Curve). UT showed an initial haemoglobin of Mdn 11.7 (IQR 9.2–14.3) g/dL and an INR value of Mdn 1.27 (IQR 1.11–1.69) as opposed to Mdn 12.3 (IQR 10–13.9) g/dL and Mdn 1.13 (IQR 1.05–1.34) in NT (haemoglobin: p = 0.786; INR: p = 0.215). There was an average number of 7.1(±3.4) rib fractures in UT and 6.7(±4.8) in NT (p = 0.649). Conclusions: Chest-tube output remains the single most important predictive factor for urgent thoracotomy also after blunt chest trauma. Patients with a chest-tube output of more than 1300 mL within 24 h after trauma should be considered for transfer to a level I trauma centre with standby thoracic surgery.

Evaluation of Lung Contusion, Associated Injuries, and Outcome in a Major Trauma Center in Shiraz, Southern Iran

Objective

Blunt chest trauma as one of the most common injuries in trauma cases can cause significant morbidity and mortality. The purpose of this study was to determine the clinical course of traumatic injuries with an initial diagnosis of a pulmonary contusion in patients.

Method

In this retrospective study, we evaluated the demographic and clinical features of patients who were referred to a major trauma center in southern Iran. In our study, patients were enrolled with the diagnosis of pulmonary contusion. All included patients were above 16 years of age, with an initial CT scan in favor of pulmonary contusion, while patients not being hospitalized for more than 48 hours were excluded from the study.

Results

Among the 434 patients included in our study, 366 (84%) were male and the mean age was 41.17 (SD = 17.89). Among them, the majority (80.4%) had right side lung contusion and 47 patients (10.8%) had right rib fracture. The most common injuries were head and neck injury (56.9%) and limbs (30%). In 25% of cases, pulmonary contusion was associated with pneumothorax and 15.8% with hemothorax. Also, 49.6% of patients were transferred to the ICU. The mortality rate in our study was 15.2% (n = 66).

Conclusion

Although recent advances in pulmonary care and ventilator management have been achieved, there is still considerable morbidity and mortality associated with this condition. Therefore, there is a need to provide a national guideline based on native patient information for better management.

Comparison of Surgical Stabilization Time in Patients with Flail Chest

BACKGROUND

This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest.

METHODS

A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization.

RESULTS

A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization.

CONCLUSION

Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Biomechanical investigation of different surgical strategies for the treatment of rib fractures using a three-dimensional human respiratory model

Rib fracture is a common injury and can result in pain during respiration. Conservative treatment of rib fracture is applied via mechanical ventilation. However, ventilator-associated complications frequently occur. Surgical fixation is another approach to treat rib fractures. Unfortunately, this surgical treatment is still not completely defined. Past studies have evaluated the biomechanics of the rib cage during respiration using a finite element method, but only intact conditions were modelled. Thus, the purpose of this study was to develop a realistic numerical model of the human rib cage and to analyse the biomechanical performance of intact, injured and treated rib cages. Three-dimensional finite element models of the human rib cage were developed. Respiratory movement of the human rib cage was simulated to evaluate the strengths and limitations of different scenarios. The results show that a realistic human respiratory movement can be simulated and the predicted results were closely related to previous study (correlation coefficient>0.92). Fixation of two fractured ribs significantly decreased the fixation index (191%) compared to the injured model. This fixation may provide adequate fixation stability as well as reveal lower bone stress and implant stress compared with the fixation of three or more fractured ribs.

The ideal methods for the management of rib fractures

The clinical treatment choices for multiple rib fractures and flail chest are controversial. For example, among conservative treatment and surgical treatment, different studies have different conclusions and recommendations. Furthermore, early clinical research was mainly focused on the treatment of flail chest due to its severity. Nowadays, the treatment for multiple rib fractures patients without a flail chest is drawing an increased clinical interest. However, we are facing many challenges for the treatment of rib fractures, such as insufficient understanding of the available treatment options, lack of clinical research, lack of the internationally recognized clinical indication for the surgical stabilization of rib fractures (SSRF), and the constant controversies and debates in terms of treatment options, surgery timing, and surgical techniques. All these challenges make it difficult to select the most appropriated clinical decisions for the proper treatment of a rib fracture, resulting in a seriously hindered development of novel rib fractures treatment choices. The concepts and ideas for traditional rib fractures treatment are relatively old, and even have some misunderstandings or errors. With the emergence of more and more research, the understandings of the rib fractures treatment has gradually improved; for example, the benefits provided to patients under the open reductions and internal fixation of fractures treatment. In this article, we outlined the new concepts in rib fractures treatment, which mainly included four parts, damage control, pain management, fixation selection, and quality of life. We hope these concepts help practitioners better manage rib fracture patients.

Disorders of the Chest Wall: Clinical Manifestations

Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome

BACKGROUND

Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course.

METHODS

We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview.

RESULTS

From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB^® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred.

CONCLUSIONS

In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Does the Coexistence of Multiple Segmental Rib Fractures in Polytrauma Patients Presenting With "Major" Vertebral Fracture Affect Care and Acute Outcomes?

OBJECTIVE

To determine whether operating on "major" vertebral fractures leads to premature abortion of surgery and/or other acute cardiopulmonary complications.

DESIGN

Retrospective review.

CLINICAL SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS AND INTERVENTION

We retrospectively queried our institutional Trauma Rregistry for all cases presenting with concomitant rib fractures and surgically managed vertebral fractures.

MAIN OUTCOME MEASUREMENTS

The main outcomes included the surgical outcome (aborted vs. successfully performed), total and Intensive Care Unit length of stay (LOS), adverse discharge, mortality, and functional outcomes.

RESULTS

We found 57 cases with concomitant segmental rib fractures and surgically managed vertebral fractures. Seven patients (12%) received a rib fixation, of which 1 received before vertebral fixation and 6 after. Importantly, 4 vertebral fixation cases (7.02%) had to be aborted intraoperatively because of the inability to tolerate prone positioning for surgery. For case-control analysis, we performed propensity score matching to obtain matched controls, that is, cases of vertebral fixation but no rib fractures. On matched case-control analysis, patients with concomitant segmental rib fractures and vertebral fractures were found to have higher Intensive Care Unit LOS [median = 3 days (Inter-Quartile Range = 0-9) versus. 8.4 days, P = 0.003], whereas total LOS, frequency of complete, incomplete or functional spinal cord injury, discharge to rehab, and discharge to nursing home were found to be similar between the 2 groups.

CONCLUSION

Our findings demonstrate that segmental rib fractures with concomitant vertebral fractures undergoing surgical treatment represent a subset of patients that may be at increased risk of intraoperative cardio-pulmonary complications and rib fixation before prone spine surgery for cases in which the neurological status is stable is reasonable.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Imaging and Management of Thoracic Trauma

Thoracic injury results from penetrating and blunt trauma and is a major contributor to overall trauma morbidity and mortality in the United States. Modern imaging algorithms utilize ultrasound, chest radiograph, and computed tomography with intravenous contrast to accurately diagnose and effectively treat patients with acute thoracic trauma. This review focuses on the etiologies, signs and symptoms, imaging, and management of several life-threatening thoracic injuries including tracheobronchial rupture, pulmonary parenchymal injury, hemothorax, pneumothorax, diaphragmatic rupture, and axial skeleton injury.

Pulmonary contusions after blunt chest trauma: clinical significance and evaluation of patient management

INTRODUCTION

A pulmonary contusion is an entity defined as alveolar haemorrhage and pulmonary parenchymal destruction after blunt chest trauma. According to the literature, most pulmonary contusions can only be seen on a chest CT. The aim of this study was to evaluate the patients with pulmonary contusions, as well as their management, considering diagnostic and therapeutic options related to their outcomes, since we assumed, based on everyday clinical practice, that an 'overdiagnosing' and 'overtreatment' attitude towards this injury could be present.

PATIENTS AND METHODS

The research was a retrospective study including 5042 patients admitted to the Department of Traumatology in the Clinical Hospital Centre Osijek, during a 3-year period. The medical data of the patients who suffered pulmonary contusion were evaluated considering significant characteristics, known risk factors, procedures undergone, and outcomes.

RESULTS

During the 3-year period, 2% of all the admitted patients were diagnosed with a pulmonary contusion. In 54% of the cases, the patient suffered polytraumatic injuries. The pulmonary contusion was an isolated injury in 7% of the patients. In 31% of the cases, there was no liquidothorax or pneumothorax (isolated pulmonary contusion). In 89% of the patients the pulmonary contusion was diagnosed using a CT scan. In 68% of the patients there were no interventions regarding the thorax; thoracocentesis was performed in 25% of the cases, and pleural punction in 14% of the cases. 25% of the patients developed respiratory insufficiency and 16% required mechanical ventilation. Regarding isolated pulmonary contusions, respiratory insufficiency was present in 8% of the cases.

CONCLUSIONS

We suggest that a pulmonary contusion seen on CT only has limited clinical significance and that the use of CT scans in diagnosing and follow-up of these patients should be re-evaluated. Further prospective and randomised studies should be conducted and the patients should be clinically evaluated, with the administration of supportive and antibiotic therapy, maintaining the fluid balance, the administration of diuretics, supportive oxygen therapy, pulmonary toilet, and physical therapy.

Management of blunt pulmonary injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures

The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n = 38) and multiple non-flail rib fracture groups (n = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.

Management of patients with flail chest by surgical fixation using claw-type titanium plate

Background

The goal of the study was to compare surgical rib fixation using claw-type titanium plate with conservative treatment in the management of patients with flail chest.

Methods

The study retrospectively studied 23 patients suffering from flail chest injury, who admitted to our hospital from October, 2010 to February, 2014. The patients received surgical fixation by using claw-type titanium plate (surgical fixation group). A age and sex-matched cohort of 29 patients received conservative treatment and defined as conservative treatment group. Outcome variables included number of cases undergoing mechanical ventilation, ventilation time, time of hospital stay, incidence of respiratory complications, incidence of thoracic deformity and postoperative forced expiratory volume in the first second (FEV1).

Results

Compared with conservative treatment group, surgical fixation group had fewer cases undergoing mechanical ventilation, shorter ventilation time, shorter hospital stay, lower incidence of respiratory complications and thoracic deformity and improved pulmonary function. Patients undergoing surgery earlier had shorter time of mechanical ventilation.

Conclusions

Surgical rib fixation with claw-type titanium plate is a reliable and efficient method in the management of patients with flail chest.

Predictors of mortality in patients with flail chest: a systematic review

OBJECTIVE

To summarise the risk factors for mortality in patients with flail chest based on available evidence in the literature.

METHODS

A systematic review was completed using articles from PubMed, EMBASE, the Centre for Review and Dissemination database and the Cochrane Library. Additional studies were identified by hand-searching bibliographies, and grey literature was sought by searching abstracts from all relevant Emergency Medicine Conferences. All published and unpublished observational studies were included if they investigated estimates of association between a risk factor and mortality for patients with flail chest.

RESULTS

This review found seven studies that matched the inclusion criteria, with a total of 944 patients. Patient age of ≥65 years was reported as a predictor of mortality when controlling for injury severity score (ISS) (p<0.02, OR 2.1, 95% CI 1.0 to 4.6). An ISS of ≥31 was reported to be a predictor of mortality in two studies; however, neither controlled for patient age. Pulmonary contusion, bilateral flail chest and hospital length of stay were not consistently found to be associated with mortality.

CONCLUSIONS

The main independent predictors of mortality in patients with flail chest were reported to be increased age and ISS. More data are needed regarding the association of hospital length of stay, presence of pulmonary contusion and bilateral flail chest.

Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion

OBJECTIVE

The objective of this study is to compare the clinical efficacy of surgical fixation and nonsurgical management of flail chest and pulmonary contusion (FC-PC) and to compare the diverse timings of surgery to discuss case management in FC-PC.

METHODS

The data of 39 patients diagnosed with FC-PC were obtained from the intensive care unit of Shanghai First People's Hospital and analyzed retrospectively from July 2010 to Dec 2013. The patients required ventilator support and were divided into a surgical group and a nonsurgical group, according to the treatment method. The clinical data, such as mortality, the duration of mechanical ventilation (DMV), intensive care unit length of stay, hospital length of stay (HLOS), days of antibiotic use, transfusion volume, medical expense as well as the incidence of tracheotomy, pleural effusion, and incidence of ventilator associated pneumonia, were collected for all subjects. The surgical group was further divided into 2 groups according to the surgery timing. Surgery within 7 days of admission was defined as early surgery, and all other times were defined as late surgery. The clinical data and incidence of incision infection were collected and compared.

RESULTS

The patients in the surgical group had a slightly shorter HLOS. No differences were noted in mortality and the other clinical data between the groups. The early surgical group had a shorter DMV and less incidence of tracheotomy. The other parameters had no differences.

CONCLUSIONS

Surgery for FC-PC could reduce the HLOS, and early surgery could decrease the DMV and the need for tracheotomy.

Management of Blunt Pulmonary Injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Stabilization of multiple rib fractures in a canine model

BACKGROUND

Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF.

METHODS

Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures.

RESULTS

No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization.

CONCLUSIONS

Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.

Article Commentary: Contemporary Management of Flail Chest

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

The role of non-invasive ventilation in blunt chest trauma: systematic review and meta-analysis

PURPOSE

Respiratory support is the mainstay for the management of patients with pulmonary contusion following blunt chest trauma. In patients not requiring immediate intubation and ventilation, the optimal respiratory management strategy is not clear. This systematic review and meta-analysis aimed to determine the efficacy of non-invasive ventilation (NIV), as compared to traditional respiratory support strategies (i.e., high-flow facemask oxygen or pre-emptive intubation and ventilation), in adult patients with blunt chest trauma.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing NIV to traditional forms of respiratory support (i.e., facemask oxygen or intubation and ventilation) in an adult trauma population. For each eligible trial, we extracted the outcomes of all-cause mortality, length of intensive care unit (ICU) stay, length of hospital stay, and pneumonia.

RESULTS

We identified 643 citations, selected 17 for full-text evaluation, and identified three eligible RCTs. Patients receiving NIV had a non-significant reduction in the risk of death (OR 0.55; 95 % CI 0.18-1.70; I (2) = 0 %), but significant reductions in length of ICU stay (mean difference -2.45 days; 95 % CI -4.27 to -0.63; I (2) = 66 %), length of hospital stay (mean difference -4.60 days; 95 % CI -8.81 to -0.39; I (2) = 85 %), and risk of pneumonia (OR 0.20; 95 % CI 0.09-0.47; I (2) = 0 %).

CONCLUSION

This meta-analysis suggests that NIV is superior to both high-flow facemask oxygen or pre-emptive intubation and ventilation in patients with blunt chest trauma who have no contraindication to NIV.

Ten-year retrospective analysis of multiple trauma complicated by pulmonary contusion

BACKGROUND

This study reports a 10-year retrospective analysis of multiple trauma complicated by pulmonary contusion. The purpose of this study is to ascertain the risk factors for mortality due to trauma in patients with pulmonary contusion, the impact of various treatment options for prognosis, and the risk factors for concurrent Acute Respiratory Distress Syndrome (ARDS).

METHODS

We retrospectively analyzed 252 trauma patients with lung contusion admitted to the General Hospital of Guangzhou Command from January 2000 to June 2011 by using the statistical processing system SPSS 17.0 for Windows.

RESULTS

We included 252 patients in our study, including 214 males and 38 females. The average age was 37.1 ± 14.9 years. There were 110 cases admitted to the ICU, of which 26 cases with ARDS. Nine of the 252 patients died. We compared those who survived with those who died by gender and age, the difference was not statistically significant (P = 0.199, P = 0.200). Separate univariate analysis of those who died and those who survived found that shock on admission (P = 0.000), coagulation disorders (P = 0.000), gastrointestinal bleeding (P = 0.02), the need for emergency surgery on admission (P = 0.000), pre-hospital intubation (P = 0.000), blood transfusion within 24 hours (P = 0.006), the use of mechanical ventilation (P = 0.000), and concurrent ARDS (P = 0.000) are poor prognosis risk factors. Further logistic analysis, including the admission GCS score (OR = 0.708, 95% CI 0.516-0.971, P = 0.032), ISS score (OR 1.135, 95% CI 1.006-1.280, P = 0.039), and concurrent ARDS (OR = 15.814, 95% CI 1.819-137.480, P = 0.012), identified the GCS score, ISS score and concurrent ARDS as independent risk factors of poor prognosis. Shock (OR = 9.121, 95% CI 0.857-97.060, P = 0.067) was also related to poor prognosis. Patients with injury factors such as road accident, falling injury, blunt injury and crush injury, et al.(P = 0.039), infection (P = 0.005), shock (P = 0.004), coagulation disorders (P = 0.006), emergency surgery (P = 0.01), pre-hospital intubation (P = 0.000), chest tube insertion (P = 0.004), blood transfusion (P = 0.000), usage of hormones (P = 0.002), phlegm (P = 0.000), ventilation (P = 0.000) were at a significantly increased risk for ARDS complications.

CONCLUSIONS

Those patients with multiple trauma and pulmonary contusion admitted to the hospital with shock, coagulopathy, a need for emergency surgery, pre-hospital intubation, and a need for mechanical ventilation could have a significantly increased risk of mortality and ARDS incidence. A risk for poor prognosis was associated with gastrointestinal bleeding. A high ISS score, high APACHE2, and low GCS score were independent risk factors for poor prognosis. If patients developed an infection or were given drainage, hormones, and phlegm treatment, they were at higher risk of ARDS. Pre-hospital intubation and drainage were independent risk factors for ARDS. In patients with ARDS, the ICU stay, total length of stay, and hospital costs might increase significantly. A GCS score < 5.5, APACHE 2 score > 16.5, and ISS score > 20.5 could be considered indicators of poor prognosis for patients with multiple trauma and lung contusion.

Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation

PURPOSE

The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma.

MATERIALS AND METHODS

Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures.

RESULTS

The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days).

CONCLUSIONS

Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits.

Blunt chest wall trauma: A review

Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.

Guidelines for Field Triage of Injured Patients: In conjunction with the Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS).1 EMS providers determine the severity of injury and begin initial management at the scene. The decisions to transport injured patients to the appropriate hospital are made through a process known as "field triage." Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process though its "Field Triage Decision Scheme." In 2005, the CDC, with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ASC-COT to convene the initial meeting of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme. This revised version was published in 2006 by ASC-COT, and in 2009 the CDC published a detailed description of the scientific rational for revising the field triage criteria entitled, "Guidelines for Field Triage of Injured Patients."2-3 In 2011, the CDC reconvened the Panel to review the 2006 Guidelines and recommend any needed changes. We present the methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.

The role of pulse oximetry in chiropractic practice: a rationale for its use

OBJECTIVE

Pulse oximetry is used regularly to assess oxygen saturation levels. The objective of this commentary is to discuss a rationale for using pulse oximetry in chiropractic practice.

DISCUSSION

Pulse oximetry may offer doctors of chiropractic a way to monitor patients' oxygen saturation levels. Quantification of saturation values with heart rate may give clinical aid to the management of chiropractic patients. Markedly reduced saturation levels may necessitate medical referral, whereas mildly reduced levels could lead to changes in chiropractic management.

CONCLUSIONS

Pulse oximetry has the potential to be an integral part of chiropractic practice.

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report

The present article reports on the successful management of a large flail chest with traumatic pulmonary herniation in a patient who could not be weaned from mechanical ventilation following a course of conservative management. Surgical intervention involved open reduction and internal fixation with tubular plates to stabilize the flail segment, followed by a pectoralis major myocutaneous flap to repair the chest wall defect. Following surgical intervention, the patient was able to be weaned from mechanical ventilation and showed remarkable improvement in pulmonary function parameters. To the authors' knowledge, the present report is the first to describe the use of open reduction and internal fixation of the chest wall and flap reconstruction to treat lung herniation with a flail chest segment.

Thoracic Injuries in earthquake-related versus non-earthquake-related trauma patients: differentiation via Multi-detector Computed Tomography

PURPOSE

Massive earthquakes are harmful to humankind. This study of a historical cohort aimed to investigate the difference between earthquake-related crush thoracic traumas and thoracic traumas unrelated to earthquakes using a multi-detector Computed Tomography (CT).

METHODS

We retrospectively compared an earthquake-exposed cohort of 215 thoracic trauma crush victims of the Sichuan earthquake to a cohort of 215 non-earthquake-related thoracic trauma patients, focusing on the lesions and coexisting injuries to the thoracic cage and the pulmonary parenchyma and pleura using a multi-detector CT.

RESULTS

The incidence of rib fracture was elevated in the earthquake-exposed cohort (143 vs. 66 patients in the non-earthquake-exposed cohort, Risk Ratio (RR) = 2.2; p<0.001). Among these patients, those with more than 3 fractured ribs (106/143 vs. 41/66 patients, RR=1.2; p<0.05) or flail chest (45/143 vs. 11/66 patients, RR=1.9; p<0.05) were more frequently seen in the earthquake cohort. Earthquake-related crush injuries more frequently resulted in bilateral rib fractures (66/143 vs. 18/66 patients, RR= 1.7; p<0.01). Additionally, the incidence of non-rib fracture was higher in the earthquake cohort (85 vs. 60 patients, RR= 1.4; p<0.01). Pulmonary parenchymal and pleural injuries were more frequently seen in earthquake-related crush injuries (117 vs. 80 patients, RR=1.5 for parenchymal and 146 vs. 74 patients, RR = 2.0 for pleural injuries; p<0.001). Non-rib fractures, pulmonary parenchymal and pleural injuries had significant positive correlation with rib fractures in these two cohorts.

CONCLUSIONS

Thoracic crush traumas resulting from the earthquake were life threatening with a high incidence of bony thoracic fractures. The ribs were frequently involved in bilateral and severe types of fractures, which were accompanied by non-rib fractures, pulmonary parenchymal and pleural injuries.

Crush thoracic trauma in the massive Sichuan earthquake: evaluation with multidetector CT of 215 cases

PURPOSE

To determine the multidetector computed tomographic (CT) features of crush thoracic traumas resulting from the massive Sichuan earthquake.

MATERIALS AND METHODS

This study was approved by the ethics committee of the medical school, and informed consent was waived. A retrospective review was undertaken of 215 multidetector chest CT scans of 112 male and 103 female patients who sustained crush thoracic injuries in the Sichuan earthquake at 2:28 pm Beijing time, May 12, 2008, and were rescued in the authors' hospital. Multidetector chest CT studies were performed between May 12, 2008, and June 7, 2008. The authors looked for injuries to the thoracic cage, pulmonary parenchyma, and pleura.

RESULTS

One hundred forty-three patients (66.5%; 95% confidence interval [CI]: 60.2%, 72.8%) had at least one rib fracture; the mean number of rib fractures per patient was 6 [corrected]. Forty-five of these patients (31.5% of 143 patients; 95% CI: 23.9%, 39.1%) had flail chest, with a total of 288 ribs fractured. There were 46 patients (21.4%; 95% CI: 15.9%, 26.9%) with at least one vertebral fracture. There were 77 vertebral fractures total; 36 of these fractures were in T1 through T10. Twelve patients (5.6%; 95% CI: 2.5%, 8.7%) had sternal fractures, and 48 patients (22.3%; 95% CI: 16.7%, 27.9%) had either scapular or clavicular fractures. There were 117 patients (54.4%; 95% CI: 47.7%, 61.1%) with pulmonary parenchymal injuries and 146 (67.9%; 95% CI: 61.7%, 74.1%) with pleural injuries.

CONCLUSION

Crush thoracic trauma resulting from the massive Sichuan earthquake was a life-threatening injury; this type of injury has the potential for multiple fractures and pulmonary parenchymal injuries.

Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial

OBJECTIVE

Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas.

MATERIALS AND METHODS

44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation-VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H(2)O and PaO(2) 60-100 mm Hg and PaCO(2) 35-45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled.

RESULTS

All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO(2)/FiO(2) significantly improved from 36 h.

CONCLUSIONS

VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.