Blunt chest trauma: review of selected pulmonary injuries focusing on pulmonary contusion

Imaging findings of pulmonary contusions on multidetector CT: A retrospective study comparing adults and children

To describe imaging findings of pulmonary contusions (PC) in adults and children using multidetector computed tomography (CT) scanners. We conducted a retrospective single center study. All chest multidetector computed tomography (MDCT) scans of victims of blunt trauma admitted to the emergency unit of a reference trauma center of Brazil between January 2015 and December 2016 were reviewed in search of opacities compatible with PC. The CT images were analyzed in conjunction with medical records, that provided demographic and clinical data. The obtained data were analyzed in the overall population and comparing children and adults. Significant P value was defined as <.05. 52.7% of patients presented bilateral opacities. Middle third, posterior and peripheral portions of the lungs were more frequently affected, in the craniocaudal, anteroposterior and axial axes, respectively. A vast majority of patients (80.6%) presented multiple opacities, whereas a minority showed subpleural sparing (26.9%) and fissure crossing (22.6%), with similar frequencies in children and adults. Children, although, more frequently presented consolidation and more diffuse lesions in the anteroposterior axis compared to adults, with statistically significant differences. PC usually are multiple and predominate in middle, posterior and peripheral portions of the lungs. Subpleural sparing and fissure crossing seems to be infrequent and have similar frequencies between children and adults. Although, there are differences between these age groups, as younger people tend to have more consolidation and diffuse opacities in the anteroposterior axis than older ones.

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.

Retrospective review of the use and costs of routine chest x rays in a trauma setting

INTRODUCTION

Chest x-rays (CXR) are routinely obtained on blunt trauma patients. Many patients also receive additional imaging with thoracic computed tomography scans for other indications. We hypothesized that in hemodynamically normal, awake and alert blunt trauma patients, CXR can be deferred in those who will also receive a TCT with significant cost savings.

METHODS

We retrospectively reviewed the charts of trauma patients from 1/1/2010 to 12/31/2010 who received both a CXR and TCT in the trauma room. Billing and cost data were collected from various hospital sources.

RESULTS

239 patients who met inclusion and exclusion criteria and received CXR and TCT between 1/1/2010 and 12/31/2010. The sensitivity of CXR was 19% (95% CI: 10.8% to 31%) and the specificity was 91.7% (95% CI: 86.7% to 95%). The false positive rate for CXR was 35.8% (95% CI: 21.7% to 52.8%) and the false negative rate was 24.5% (95% CI: 18.8% to 31.2%). The precision of CXR was 42.3% (95% CI: 25.5% to 61.1%) and the overall accuracy was 74.1% (95% CI: 68.1% to 79.2%). If routine chest xray were eliminated in these patients, the estimated cost savings ranged from $14,641 to $142,185, using three different methods of cost analysis.

CONCLUSIONS

In patients who are hemodynamically normal and who will be receiving a TCT, deferring a CXR would result in an estimated cost savings up to $142,185. Additionally, TCT is more sensitive and specific than CXR in identifying injuries in patients who have sustained blunt trauma to the thorax.

Diagnostic value of ischaemia-modified albumin in pulmonary contusion in rats

BACKGROUND

Patients with pulmonary contusion (PC) are at increased risk of development of complications and death after trauma. The early diagnosis and determination of severity of PC could improve clinical outcomes. The aim of the study was to determine the diagnostic value of ischaemia-modified albumin (IMA) in a PC model in rats.

METHODS

Thirty-two Sprague-Dawley rats were randomly allocated to four groups; the uninjured control Group I (n=7) and the uninjured control Group II (n=7) were euthanised at 2 and 6h, respectively, and PC groups III (n=9) and IV (n=9) were euthanised at 2 and 6h after trauma, respectively. The serum level of IMA, tissue and serum malondialdehyde (MDA) levels, and histopathological damage scores of the lung tissue were determined.

RESULTS

Serum IMA and lung tissue MDA levels in the PC groups were not significantly different to those of the control groups (p=0.555; p=0.086, respectively). Serum MDA levels were significantly higher in the PC groups than in the control groups (p=0.011). When histopathological changes in lung parenchyma were evaluated, there was a statistical difference between the injured and uninjured groups for inflammation and lung injury (p=0.017; p=0.001, respectively). However, there was no significant correlation between the histopathological score and biochemical parameters.

CONCLUSION

Our preliminary findings suggest that there is no significant change of serum IMA levels in the acute phase of PC induced by blunt chest trauma.

Changes in the patterns, presentation and management of penetrating chest trauma patients at a level II trauma centre in southern Pakistan over the last two decades

Penetrating chest trauma can be used as an indicator of violence in the country. We aimed to look at the changes in its incidence and management at a major trauma centre in the country. We also wanted to look at any effect of prehospital time on surgical intervention and outcome of the victim. In this retrospective descriptive study, we observed the presentation and management of 191 penetrating chest injury patients at a level II trauma hospital in Pakistan in the last 20 years. The study sample was divided into two groups: Group 1, 1988-1998 and Group 2, 1999-2009. No significant change in incidence of trauma was observed between the two groups. The delay in the time between event and arrival showed an increase in the number of surgical procedures performed. Also the number of thoracotomies performed went up significantly in the second decade from 5.7 to 16.5% with a P<0.05. Six (3.1%) mortality cases were observed in 20 years. It was seen that the greater the prehospital time, the greater the chances of surgery. Also seen was the increase in mortality as critical cases could make it to the hospital alive in recent times due to improved transportation services.

Open pneumothorax resulting from blunt thoracic trauma: a case report

Cases of open pneumothorax have been documented as early as 326 BC. Until the last 50 years, understanding of the epidemiology and treatment of penetrating chest trauma has arisen from military surgery. A better understanding of cardiopulmonary dynamics, advances in ventilatory support, and improvement in surgical technique have drastically improved treatment and increased the survival rate of patients with penetrating thoracic trauma. Open pneumothorax is rare in blunt chest trauma, but can occur when injury results in a substantial loss of the chest wall. This case study presents an adolescent who sustained a large open pneumothorax as a result of being run over by a car. Early and appropriate surgical intervention coupled with coordinated efforts by all members of the trauma team resulted in a positive outcome for this patient.

Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients?

BACKGROUND

The ATLS Course advocates that injured patients have a chest x-ray (CXR) to identify potential injuries. The purpose of this study was to correlate clinical indications and clinician judgment with CXR results to ascertain if a selective policy would be beneficial.

METHODS

Patients treated at a Level I trauma center over 12 months were prospectively evaluated. Before obtaining a CXR, signs, symptoms, and history suggestive of thoracic injury were identified. Additionally, a trauma surgeon (TS) recorded whether in their judgment a CXR was clinically indicated. These findings were compared with final CXR diagnoses. The sensitivity of individual clinical indicators, combinations of clinical indicators, and TS judgment for CXR abnormalities were calculated with a 95% confidence interval.

RESULTS

During the twelve-month study period, data were acquired on 772 patients (age 0-102 years). Seventy percent were male and 86.0% were injured by blunt force. Only 29% (N = 222) of the patients manifested one or more of the clinical indicators (signs and symptoms). The negative predictive value for the TS judgment was 98.2% which was superior to the clinical indicators. Reliance on the opinion of the TS to determine the need for a CXR would have eliminated 49.9% of CXRs and avoided hospital and radiologist reading charges totaling $100,078.22.

CONCLUSION

Mandatory CXR for all trauma patients has a low yield for abnormal findings. A selective policy relying on surgical judgment guided by clinical indicators is safe and efficacious while reducing cost and conserving resources.