Thoracic Trauma: an Analysis of 187 Patients

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review

BACKGROUND

Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days).

METHODS

Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0.

RESULTS

For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia.

CONCLUSION

In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Thoracic trauma in national hospital Abuja, Nigeria: The epidemiology, injury severity and initial management options

Background

Trauma is the leading cause of death in individuals between the ages of 1 and 44 years and it is the third commonest cause of death regardless of age. Thoracic trauma is a relatively common cause of preventable death among trauma patients. The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. This study is intended to discuss the epidemiology, severity and initial management strategies in chest trauma patients, in a low income country.

Methods

A cross sectional retrospective study among chest trauma patients seen in the emergency room of National Hospital Trauma Centre, Abuja, Nigeria, from January 2015 to December 2017. Relevant patients' information was retrieved from the trauma registry kept in the trauma centre. Data processing and analysis was done using statistical package for social sciences (SPSS) version 24. Test of significance was done where applicable using chi square and student t test, using p value less than 0.05 as significant. Results are presented in tables and figures.

Results

A total of 637 patients, male to female ratio of 3.6 and mean age of 34.18 ± 11.34 were enrolled into the study. The most common mechanisms of injury were MVC (54.6%) and assault (23.5%). Blunt injuries were 3.5 times more frequent than the penetrating injuries. The RTS of 12 (76.3%) and the ISS of 1-15 category (52.3%) were the most common scores. Up to 98% of patients were managed non-operatively. Recovery rate was high (89%) with relatively low mortality rate of 4.2%.

Conclusion

Majority of thoracic trauma can be managed effectively by employing simple, non-operative procedures such as needle decompression and chest tube insertion. Efforts should be made to include these procedures in the skill set of every medical officer working in the emergency room, particularly in low and middle income countries where there is paucity of emergency physicians.

Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial

BACKGROUND

Serratus anterior plane block (SAPB) was evaluated that in patients with the complaint of rib fracture pain in terms of total analgesic consumption and pain scores.

METHOD

Sixty patients with rib fracture and NRS (Numeric Rating Scala) pain scores equal or greater than four were included in randomized controlled study. Patients were randomized to perform SAPB or control group. Primary outcome was total tramadol consumption in 24 h. Secondary outcomes were NRS scores (after Patient Controlled Analgesia (PCA) application 30 min, first, second, 4 th, 6 th, 12 th, 24 th hour), peripheral oxygen saturation (first and 24 th hour after PCA application), chronic pain. and complications.

RESULTS

The total tramadol consumption significantly lower in group S (p = 0.02). NRS scores after 30 min, 1 h, 2 h, 4 h, 6 h, 12 h, and 24 h were significantly lower in group S than in group C (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, p = 0.026). The total number of patients who reported of chronic pain at rest and during effort was significantly lower in group SAPB than in group C (p = 0.006). Nine patients in group C were reported of pain, four of whom had pain at rest and five had pain during effort. One patient in group S was reported of pain during effort.

CONCLUSION

This study demonstrated that SAPB, as part of multimodal analgesia in pain management due to rib fractures, is safe and effective in reducing acute pain.

Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial

Background

An incentive spirometer (IS) is a mechanical device that promotes lung expansion. It is commonly used to prevent postoperative lung atelectasis and decrease pulmonary complications after cardiac, lung, or abdominal surgery. This study explored its effect on lung function and pulmonary complication rates in patients with rib fractures.

Methods

Between June 2014 and May 2017, 50 adult patients with traumatic rib fractures were prospectively investigated. Patients who were unconscious, had a history of chronic obstructive pulmonary disease or asthma, or an Injury Severity Score (ISS) ≥ 16 were excluded. Patients were randomly divided into a study group (n = 24), who underwent IS therapy, and a control group (n = 26). All patients received the same analgesic protocol. Chest X-rays and pulmonary function tests (PFTs) were performed on the 5th and 7th days after trauma.

Results

The groups were considered demographically homogeneous. The mean age was 55.2 years and 68% were male. Mean pretreatment ISSs and mean number of ribs fractured were not significantly different (8.23 vs. 8.08 and 4 vs. 4, respectively). Of 50 patients, 28 (56%) developed pulmonary complications, which were more prevalent in the control group (80.7% vs. 29.2%; p = 0.001). Altogether, 25 patients had delayed hemothorax, which was more prevalent in the control group (69.2% vs. 29.2%; p = 0.005). Two patients in the control group developed atelectasis, one patient developed pneumothorax, and five patients required thoracostomy. PFT results showed decreased forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV₁) in the control group. Comparing pre- and posttreatment FVC and FEV₁, the study group had significantly greater improvements (p < 0.001).

Conclusions

In conclusion, the use of an IS reduced pulmonary complications and improved PFT results in patients with rib fractures. The IS is a cost-effective device for patients with rib fractures and its use has clinical benefits without harmful effects.

Trial registration

ClinicalTrials.gov, NCT04006587. Registered on 3 July 2019.

Thoracic trauma: principles of early management

Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.

Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review

Purpose

Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest.

Methods

Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results.

Results

Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES −6.5 days 95 % CI (−11.9, −1.2)], duration of ICU stay [ES −5.2 days 95 % CI (−6.2, −4.2)], duration of hospital stay (DHS) [ES −11.4 days 95 % CI (−12.4, −10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00–14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies.

Conclusions

Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients’ outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.

Penetrating Chest Trauma in Nigeria

Penetrating chest trauma occurs worldwide, and various accounts of it have been reported in the literature. 1 – 5 Blunt trauma is not usually associated with military or civilian violence, while penetrating chest trauma often is. Penetrating chest trauma is frequently caused by gunshots and non gunshot-related incidents such as stabs, traffic accidents, and impalements. This prospective study was conducted to determine a pattern of penetrating thoracic injuries, including their causes, the role of surgery, and intervention outcomes. In this study, we treated 168 patients (142 males and 26 females, giving a male-to-female ratio of 5.5:1). Gunshots caused 60.1% of the injuries while traffic accidents caused 27.3% of the injuries. Chest tube insertion alone was the main treatment initiated. This technique was used on 73.8% of the patients. To reduce the occurrence of penetrating chest trauma in Lagos, Nigeria, study results suggest that the Nigerian people and their property need greater security, and that pre-hospital level of care for trauma victims must improve.

[Imaging of blunt chest trauma]

CLINICAL/METHODOLOGICAL ISSUE

Blunt chest trauma is associated with high morbidity and mortality. Consequently, all patients should be evaluated radiologically after blunt chest trauma to allow timely and appropriate treatment.

STANDARD RADIOLOGICAL METHODS

Conventional chest radiographs and computed tomography (CT) are proven modalities with which to evaluate patients after blunt chest trauma.

METHODOLOGICAL INNOVATIONS

Over the last several years extended focused assessment with sonography for trauma (eFAST) has gained increasing importance for the initial assessment of seriously injured patients.

PRACTICAL RECOMMENDATIONS

In the acute phase of severely injured patients eFAST examinations are helpful to exclude pneumothorax, hemothorax and hemopericardium. Chest radiographs may also be used to diagnose a pneumothorax or hemothorax; however, the sensitivity is limited and CT is the diagnostic modality of choice to evaluate severely injured patients.

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study

INTRODUCTION

Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH.

METHODS

We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived.

RESULTS

328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH.

CONCLUSIONS

To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.

[Hypothermia at admission increases the risk of pulmonary contusion's infection in intubated trauma patients]

OBJECTIVES

Pulmonary contusion (PC) is common in cases of polytrauma. The aim of this study was to perform a multivariate analysis of risk factors associated with the occurrence of infection in PC and analyze the microbiological epidemiology.

PATIENTS AND METHODS

All patients with PC admitted to the intensive care unit (ICU) between January 2002 and December 2006 were included in this retrospective observational study. Patients with penetrating thoracic trauma or those who died in the 48hours following admission to hospital were excluded. Diagnosis of bacterial infection in PC was performed if hyperthermia was associated with a positive quantitative culture (103 colony forming units/mL) on the bronchial sample. Univariate analysis provided statistical difference between variables that were integrated in the multivariate analysis model. Multivariate analysis was then performed to determine the risk factors of bacterial infection in PC.

RESULTS

One hundred and seventeen patients were included. The incidence of bacterial infection in PC was 33.3% (39 patients). The most frequently encountered bacteria were Haemophilus sp., Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Streptococcus sp. According to multivariate analysis, the existence of hypothermia at hospital admission increased the risk of PC infection (OR=2.61; IC 95% [4.2-13.3]).

CONCLUSION

In conclusion, PC was infected in 33.3% of cases. The existence of hypothermia was identified as a risk factor. A prospective study is warranted to confirm these results.

Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases

Background

Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria.

Methods

We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality.

Results

The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%).

Conclusions

New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis.

Article Commentary: Rib Fracture Fixation: Controversies and Technical Challenges

Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and mortality. The social and economic costs that rib fractures contribute to the health care burden of the United States are therefore significant. But despite this measurable impact on patients’ quality of life, current treatment of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports from American centers support an increased application of operative fixation. With this resurgent interest of American surgeons in mind, we review the clinical presentations, potential indications, controversies, and technical challenges unique to rib fracture fixation.

Etiopathology and management challenges of blunt chest trauma in Nigeria

Blunt chest trauma had not been roundly studied in Nigeria. This study was conducted to determine the etiopathological and management challenges of chest trauma in a developing country. In a prospective multicenter hospital-based study of 10-years duration in the city of Lagos, the data of 896 patients were recorded. The male-to-female ratio was 8 : 1, and the mean age was 27.1 years. The majority of patients (76.9%) were aged 20-39 years. Road traffic accidents caused 98.1% of the injuries. Lung parenchymal injuries occurred in 66% of patients, and cardiac trauma in 0.1%. Isolated chest trauma was found in 85% of patients, and 134 had associated injuries. The incidence of blunt chest trauma could be reduced if the number of road traffic accidents in Nigeria is reduced.

[Thorax injuries]

Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.

[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.

Pneumopericardium in blunt chest trauma after high-speed motor vehicle accidents

Pneumopericardium is the presence of air in the pericardial space. In adults, it may be seen in the context with severe blunt chest trauma, pneumothorax, pneumoperitoneum, or other causes of pneumomediastinum. The diagnosis is made by computed tomography scan of the thorax and abdomen that allows the additional detection of concomitant injuries. Possible causes of the pneumopericardium such as tracheobronchial or oesophageal tears have to be excluded by bronchoscopy or esophagogastroduodenoscopy. Usually, pneumopericardium is self-limiting requiring no specific therapy. However, a continuous monitoring of the electrocardiography and the blood pressure is necessary at an intermediate care unit. Tension pneumopericardium causing a life-threatening cardiac tamponade requires an immediate pericardial aspiration, the subsequent pericardial drainage via a pericardial window or emergent open subxyphoid approach to the pericardium.

Infrared thermography: a rapid, portable, and accurate technique to detect experimental pneumothorax

RATIONALE AND OBJECTIVE

Pneumothorax (Ptx) is a life-threatening complication that can result from trauma, mechanical ventilation, and invasive procedures. Infrared thermography (IRT), a compact and portable technology, has become highly sensitive. We hypothesized that IRT could detect Ptx by identifying associated changes in skin temperature.

MATERIALS AND METHODS

Bilateral nonpenetrating chest incisions or needle punctures were performed in 21 anesthetized rats. Rats were then randomized to no, bilateral, left, or right Ptx by either open (n = 16) or closed percutaneous (n = 5) puncture through selected pleurae. Real-time thermographic images and surface temperature data were acquired with a noncooled infrared camera.

RESULTS

In all cases, blinded observers correctly identified each Ptx with real-time grayscale image analysis. When compared to either the ipsilateral baseline or an abdominal reference, experimental Ptx produced a significantly greater decrease in surface temperature when compared to non-Ptx control.

CONCLUSIONS

These results demonstrate that portable infrared imaging can rapidly and accurately detect changes in thoracic surface temperature associated with experimental pneumothorax.