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Merkl T, Astapenko D, Štichhauer R, Šafus A, Dušek T, Kotek J, Řehák D, Lochman P. Exogenous surfactant for lung contusion causing ARDS: A systematic review of clinical and experimental reports. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13776. [PMID: 38778673 PMCID: PMC11112292 DOI: 10.1111/crj.13776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/14/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024]
Abstract
This systematic review aimed to summarize the available data on the treatment of pulmonary contusions with exogenous surfactants, determine whether this treatment benefits patients with severe pulmonary contusions, and evaluate the optimal type of surfactant, method of administration, and drug concentration. Three databases (MEDline, Scopus, and Web of Science) were searched using the following keywords: pulmonary surfactant, surface-active agents, exogenous surfactant, pulmonary contusion, and lung contusion for articles published between 1945 and February 2023, with no language restrictions. Four reviewers independently rated the studies for inclusion, and the other four reviewers resolved conflicts. Of the 100 articles screened, six articles were included in the review. Owing to the limited number of papers on this topic, various types of studies were included (two clinical studies, two experiments, and two case reports). In all the studies, surfactant administration improved the selected ventilation parameters. The most frequently used type of surfactant was Curosurf® in the concentration of 25 mg/kg of ideal body weight. In most studies, the administration of a surfactant by bronchoscopy into the segmental bronchi was the preferable way of administration. In both clinical studies, patients who received surfactants required shorter ventilation times. The administration of exogenous surfactants improved ventilatory parameters and, thus, reduced the need for less aggressive artificial lung ventilation and ventilation days. The animal-derived surfactant Curosurf® seems to be the most suitable substance; however, the ideal concentration remains unclear. The ideal route of administration involves a bronchoscope in the segmental bronchi.
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Affiliation(s)
- Tomáš Merkl
- Military Faculty of Medicine, Department of Military SurgeryUniversity of DefenceHradec KraloveCzech Republic
- Department of Pediatric Surgery and Traumatology, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
| | - David Astapenko
- Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
- Faculty of Health StudiesTechnical University in LiberecLiberecCzech Republic
| | - Radek Štichhauer
- Department of Pediatric Surgery and Traumatology, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
| | - Antonín Šafus
- Department of Pediatric Surgery and Traumatology, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
| | - Tomáš Dušek
- Military Faculty of Medicine, Department of Military SurgeryUniversity of DefenceHradec KraloveCzech Republic
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
- Department of Surgery, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
| | - Jiří Kotek
- Military Faculty of Medicine, Department of Military SurgeryUniversity of DefenceHradec KraloveCzech Republic
- Department of Surgery, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
| | - David Řehák
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
| | - Petr Lochman
- Military Faculty of Medicine, Department of Military SurgeryUniversity of DefenceHradec KraloveCzech Republic
- Faculty of Medicine in Hradec KraloveCharles UniversityPragueCzech Republic
- Department of Surgery, University Hospital Hradec Kralove, Faculty of Medicine Hradec KraloveCharles UniversityPragueCzech Republic
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Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. Acad Emerg Med 2024; 31:316-325. [PMID: 37843475 DOI: 10.1111/acem.14820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/30/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES The primary objective was to compare the analgesic efficacy of ultrasound-guided erector spinae plane block (ESPB) with a sham procedure in adult patients presenting with rib fractures to the emergency department (ED). METHODS A randomized controlled trial was conducted at an academic ED over a 17-month period. Forty-six adults with confirmed rib fractures and numeric rating score (NRS) greater than 4 were randomized to one of two treatment arms: ultrasound-guided ESPB group or placebo (sham procedure). Intravenous opioids were prescribed as rescue analgesia when self-reported pain scores were ≥4. The primary outcome measure, pain intensity reduction, was derived using the 11-point NRS at six time points over 12 h. Secondary outcome measures included the amount of rescue analgesia, in morphine equivalents, and the occurrence of adverse events. Two-way repeated-measures ANOVA was used to compare the trend in NRSs across the two arms. The association between the complications and intervention was explored using the Fisher's exact test. RESULTS Forty-six patients (23 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, vital signs, preenrollment analgesia, or baseline pain intensity. In comparing pain intensity during the study period, NRS scores at 30, 60, and 120 min were significantly lower in the ESPB group (p < 0.001) during rest and deep inspiration. Moreover, patients in the ESPB group received lesser rescue analgesia than those in the sham group (10 mg, IQR 2.5 vs. 20 mg, IQR 5 mg; p ≤ 0.01). There was no difference in adverse events between groups. CONCLUSIONS Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period and reduced amount of rescue analgesia and had no discernible difference in adverse events when compared with a sham.
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Affiliation(s)
- Swetha Ramesh
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - S Manu Ayyan
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Durga Prasad Rath
- Department of Cardiovascular and Thoracic Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Deepthy Melepurakkal Sadanandan
- Research Scientist and Biostatistician, Women's & Children's Health Research Unit, Jawaharlal Nehru Medical College of KLE Academy of Higher Education and Research (KAHER), Puducherry, India
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Lagazzi E, Rafaqat W, Argandykov D, de Roulet A, Abiad M, Proaño-Zamudio JA, Velmahos GC, Hwabejire JO, Paranjape C, Albutt KH. Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion. Surgery 2024; 175:529-535. [PMID: 38167568 DOI: 10.1016/j.surg.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/09/2023] [Accepted: 09/05/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy. https://twitter.com/EmanueleLagazzi
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charudutt Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Katherine H Albutt
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Van Wijck SFM, Smith EF, Werner NL, Madden K, Moore EE, Wijffels MME, Pieracci FM. Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern? Am Surg 2024; 90:261-269. [PMID: 37646136 DOI: 10.1177/00031348231198111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.
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Affiliation(s)
- Suzanne F M Van Wijck
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Elizabeth F Smith
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Nicole L Werner
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Kelley Madden
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
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Nobe R, Nakao S, Nakagawa Y, Ogura H, Shimazu T, Oda J. Association between lung contusion volume and acute changes in fibrinogen levels: A single-center observational study. Acute Med Surg 2024; 11:e945. [PMID: 38558758 PMCID: PMC10979042 DOI: 10.1002/ams2.945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Aim Organ tissue damage, including the lungs, may lead to acute coagulopathy. This study aimed to evaluate the association between lung contusion volume and serum fibrinogen level during the acute phase of trauma. Methods We conducted an observational study using electronic medical records at a tertiary-care center between January 2015 and December 2018. We included patients with lung contusions on hospital arrival. We used three-dimensional computed tomography to calculate lung contusion volumes. The primary outcome was the lowest fibrinogen level measured within 24 h of hospital arrival. We evaluated the association between lung contusion volume and outcome with multivariable linear regression analysis. Also, we calculated the sensitivity and specificity of lung contusion volume in patients with a serum fibrinogen level of ≤150 mg/dL. Results We identified 124 eligible patients. Their median age was 43.5 years, and 101 were male (81.5%). The median lung contusion volume was 10.9%. The median lowest fibrinogen level within 24 h from arrival was 188.0 mg/dL. After adjustment, lung contusion volume had a statistically significant association with the lowest fibrinogen level within 24 h from arrival (coefficient -1.6, 95% confidence interval -3.16 to -0.07). When a lung contusion volume of 20% was used as the cutoff, the sensitivity and specificity to identify fibrinogen depletion were 0.27 and 0.95, respectively. Conclusion Lung contusion volume was associated with the lowest fibrinogen level measured within 24 h from hospital arrival. Measuring lung contusion volume may help to identify patients with a progression of fibrinogen depletion.
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Affiliation(s)
- Ryosuke Nobe
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuita, OsakaJapan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuita, OsakaJapan
| | - Yuko Nakagawa
- Emergency and Critical Care CenterHyogo Prefectural Nishinomiya HospitalNishinomiyaJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuita, OsakaJapan
| | | | - Jun Oda
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuita, OsakaJapan
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Bethlahmy JM, Hanst BA, Giafaglione SM, Elia JM. Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review. J Clin Anesth 2023; 91:111275. [PMID: 37797395 DOI: 10.1016/j.jclinane.2023.111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
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.
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Affiliation(s)
- Jessica M Bethlahmy
- UC Irvine School of Medicine, 1001 Health Sciences Road Irvine, CA 92617, USA
| | - Brian A Hanst
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Sarah M Giafaglione
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Jennifer M Elia
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA.
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Karlsson T, Olsson LG, Gustavsson J, Arborelius UP, Risling M, Günther M. An Experimental Cold Gas Cannon for the Study of Porcine Lung Contusion and Behind Armor Blunt Trauma. Ann Biomed Eng 2023; 51:2762-2771. [PMID: 37532895 PMCID: PMC10632235 DOI: 10.1007/s10439-023-03334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
Behind armor blunt trauma (BABT) is a non-penetrating injury caused by the rapid deformation of body armor, by a projectile, which may in extreme circumstances cause death. The understanding of the mechanisms is still low, in relation to what is needed for safety threshold levels. Few models of graded kinetic energy transfer to the body exist. We established an experimental model for graded BABT. The cold gas cannon was air-driven, consisted of a pressure vessel, a barrel, and a pressure actuator. It required short training to operate and was constructed by standard components. It produced standardized expulsion of plastic projectiles with 65 mm and weight 58 g. Velocity correlated linearly to pressure (R 0.9602, p < 0.0001), equation Y = 6.558*X + 46.50. Maximum tested pressure was 10 bar, velocity 110 m/s and kinetic energy (Ek) 351 J. Crossbred male swine (n = 10) mean weight (SD) 56 ± 3 kg, were subjected to BABT, mean Ek (SD) 318 (61) J, to a fix point on the right lateral thorax. Pulmonary contusion was confirmed by physiological parameters pO2 (p < 0.05), SaO2 (p < 0.01), pCO2 (p < 0.01), etCO2 (p < 0.01), MPAP (p < 0.01), Cstat (p < 0.01), intrapulmonary shunt (Q's/Q't) (p < 0.05), and qualified trans-thoracic ultrasound (p < 0.0001). The consistent injury profile enabled for the addition of future experimental interventions.
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Affiliation(s)
- Tomas Karlsson
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care, Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Lars-Gunnar Olsson
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden
| | - Jenny Gustavsson
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden
| | - Ulf P Arborelius
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden
| | - Mårten Risling
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden
| | - Mattias Günther
- Section of Experimental Traumatology, Department of Neuroscience, Karolinska Institutet, Biomedicum - 8B, 171 77, Stockholm, Sweden.
- Section of Anesthesiology and Intensive Care, Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
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Bassiri A, Badrinathan A, Kishawi S, Sinopoli J, Linden PA, Ho VP, Towe CW. Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2046. [PMID: 38004095 PMCID: PMC10673139 DOI: 10.3390/medicina59112046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.
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Affiliation(s)
- Aria Bassiri
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Avanti Badrinathan
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Sami Kishawi
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Jillian Sinopoli
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Philip A. Linden
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH 44109, USA;
| | - Christopher W. Towe
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
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Seok J, Jeong ST, Yoon SY, Lee JY, Kim S, Cho H, Kang WS. Novel nomogram for predicting paradoxical chest wall movement in patients with flail segment of traumatic rib fracture: a retrospective cohort study. Sci Rep 2023; 13:20251. [PMID: 37985825 PMCID: PMC10662329 DOI: 10.1038/s41598-023-47700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/17/2023] [Indexed: 11/22/2023] Open
Abstract
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.
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Affiliation(s)
- Junepill Seok
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, 28644, South Korea
| | - Soon Tak Jeong
- Department of Physical Medicine and Rehabilitation, Ansanhyo Hospital, Ansan City, Republic of Korea
| | - Su Young Yoon
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, 28644, South Korea
| | - Jin Young Lee
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, 28644, South Korea
| | - Seheon Kim
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, 28644, South Korea
| | - Hyunmin Cho
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, 65, Doryeong-ro, Jeju-si, Jeju-do, Republic of Korea
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, 65, Doryeong-ro, Jeju-si, Jeju-do, Republic of Korea.
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10
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Elkins MR. Physiotherapy management of rib fractures. J Physiother 2023; 69:211-219. [PMID: 37714770 DOI: 10.1016/j.jphys.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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11
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Alanwer KM, Refat AM, Negm EM. Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country. BMC Anesthesiol 2023; 23:229. [PMID: 37403012 DOI: 10.1186/s12871-023-02185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/18/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.
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Affiliation(s)
- Khaled M Alanwer
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ali Mohammed Refat
- Cardiothoracic Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essamedin M Negm
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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12
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Simmonds A, Smolen J, Ciurash M, Alexander K, Alwatari Y, Wolfe L, Whelan JF, Bennett J, Leichtle SW, Aboutanos MB, Rodas EB. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. J Trauma Acute Care Surg 2023; 94:532-537. [PMID: 36949054 DOI: 10.1097/ta.0000000000003809] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Alexander Simmonds
- From the Division of Acute Care Surgery, Department of Surgery (A.S., K.A., Y.A., L.W., J.F.W., J.B., S.W.L., M.B.A., E.B.R.), Virginia Commonwealth University, and Virginia Commonwealth University School of Medicine (J.S., M.C.), Richmond, Virginia
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13
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Brewer JM, Huselid R, Petitpas KM, Jayaraman V, Russel Hill T, Greig C, McGuiness C, McLaughlin E, Montgomery SC, Shapiro DS, Moutinho M, Doben AR. Creating a Chest Wall Injury and Reconstructive program: A single center experience with rib fractures. Injury 2022; 53:4013-4019. [PMID: 36210206 DOI: 10.1016/j.injury.2022.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/08/2022] [Accepted: 09/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND New Chest Wall Injury and Reconstructive Centers (CWIRC) are emerging; this study aims to investigate the potential benefits of implementing a CWIRC at a single institution. We hypothesized that patients treated at CWIRC will have improved outcomes. METHODS We instituted a CWIRC in 2019 at our American College of Surgeons (ACS) Level One Trauma Center. We retrospectively compared trauma patients with rib fractures who presented to our center 18 months before (PRE-C) and 18 months after CWIRC implementation (POST-C). Outcomes measured included mortality, length of stay (LOS), intensive care unit (ICU-LOS), readmission rates, and unplanned ICU admission. RESULTS There were 192 PRE-C patients, compared to 388 POST-C. The mortality in PRE-C was not significantly different compared to the POST-C group (11.46% vs 8.8%, p=0.308). There were also no differences in LOS, ICU-LOS, readmission, and unplanned ICU admission. ICU utilization was dramatically different: PRE-C 17.8% were admitted to ICU compared to 35.6% POST-C (p<0.0001). CONCLUSIONS The number of patients admitted with rib fractures to our center nearly doubled after CWIRC establishment. Early diagnosis and triage led to significantly more admissions to higher levels of care. There are trends toward improved outcomes using practice management protocols, albeit with higher ICU utilization. Establishment of a CWIRC should be considered for level 1 ACS trauma centers and as utilization of established CWIRC protocols are increased, patients will have improved outcomes. LEVEL OF EVIDENCE IV STUDY TYPE: Retrospective chart review.
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Affiliation(s)
- Jennifer M Brewer
- Department of General Surgery, University of Connecticut School of Medicine, Farmington, USA.
| | - Rachel Huselid
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, USA.
| | - Kaitlyn M Petitpas
- Department of General Surgery, University of Connecticut School of Medicine, Farmington, USA.
| | - Vijay Jayaraman
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - T Russel Hill
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Chasen Greig
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Carol McGuiness
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Erin McLaughlin
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | | | - David S Shapiro
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Manuel Moutinho
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Andrew R Doben
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
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14
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Dehghan N, Nauth A, Schemitsch E, Vicente M, Jenkinson R, Kreder H, McKee M. Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial. JAMA Surg 2022; 157:983-990. [PMID: 36129720 PMCID: PMC9494266 DOI: 10.1001/jamasurg.2022.4299] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022]
Abstract
Importance Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking. Objective To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management. Design, Setting, and Participants This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021. Interventions Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment. Main Outcomes and Measures The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy). Results A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment. Conclusions and Relevance The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated. Trial Registration ClinicalTrials.gov Identifier: NCT01367951.
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Affiliation(s)
- Niloofar Dehghan
- The CORE Institute, Phoenix, Arizona
- University of Arizona College of Medicine Phoenix, Phoenix
| | - Aaron Nauth
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Milena Vicente
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Richard Jenkinson
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hans Kreder
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael McKee
- University of Arizona College of Medicine Phoenix, Phoenix
- Banner University Medical Center, Phoenix, Arizona
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15
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"Fighting the Minotaur" a Complex Blunt Chest Trauma Due to a Bull Attack: A Case Report. Rom J Anaesth Intensive Care 2022; 28:36-39. [PMID: 36846540 PMCID: PMC9949006 DOI: 10.2478/rjaic-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Bull-related injury continues to contribute to an unacceptable number of serious injuries and deaths, and bullfighting continues to be a popular, deeply traditional celebration of the culture of many Iberic-American countries. Most accidents due to bull attacks are horn-related penetrating traumas. Blunt chest trauma can cause a wide range of clinical presentations and injuries, making the diagnostics and therapies extremely challenging. Consequently, it is vital to quickly identify major life-threatening chest wall and intrathoracic injuries. In this case report, we aimed to describe the complexity of the management and the treatment of a blunt trauma patient hit by a bull.
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16
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Zhang B, Li GK, Wang YR, Wu F, Shi SQ, Hang X, Feng QL, Li Y, Wan XY. Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis. Front Surg 2022; 9:944971. [PMID: 36211272 PMCID: PMC9537817 DOI: 10.3389/fsurg.2022.944971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients. Methods A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival. Results According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01. Conclusions NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.
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Affiliation(s)
- Bing Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gong-Ke Li
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yu-Rong Wang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Fei Wu
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Su-Qin Shi
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xin Hang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qin-Ling Feng
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yong Li
- Department of Critical Care Medicine, affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xian-Yao Wan
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
- Correspondence: Xian-Yao Wan Yong Li
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17
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Lucena-Amaro S, Cole E, Zolfaghari P. Long term outcomes following rib fracture fixation in patients with major chest trauma. Injury 2022; 53:2947-2952. [PMID: 35513938 DOI: 10.1016/j.injury.2022.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/30/2022] [Accepted: 04/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Severe chest injuries are associated with significant morbidity and mortality. Surgical rib fixation has become a more commonplace procedure to improve chest wall mechanics, pain, and function. The aim of this study was to characterise the epidemiology and long-term functional outcomes of chest trauma patients who underwent rib fixation in a major trauma centre (MTC). METHODOLOGY This was a retrospective review (2014-19) of all adult patients with significant chest injury who had rib fixation surgery following blunt trauma to the chest. The primary outcome was functional recovery after hospital discharge, and secondary outcomes included length of intensive care unit (ICU) and hospital stay, maximum organ support, tracheostomy insertion, ventilator days. RESULTS 60 patients underwent rib fixation. Patients were mainly male (82%) with median age 52 (range 24-83) years, injury severity score (ISS) of 29 (21-38), 10 (4-19) broken ribs, and flail segment in 90% of patients. Forty-six patients (77%) had a good outcome (GOSE grade 6-8). Patients in the poor outcome group (23%; GOSE 1-5) tended to be older [55 (39-83) years vs. 51 (24-78); p = 0.05] and had longer length of hospital stay [42 (19-82) days vs. 24 (7-90); p<0.01]. Injury severity, rate of mechanical ventilation or organ dysfunction did not affect long term outcome. Nineteen patients (32%) were not mechanically ventilated. CONCLUSIONS Rib fixation was associated with good long-term outcomes in severely injured patients. Age was the only predictor of long-term outcome. The results suggest that rib fixation be considered in patients with severe chest injuries and may also benefit those who are not mechanically ventilated but are at risk of deterioration.
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Affiliation(s)
- Susana Lucena-Amaro
- Adult Critical care Unit, The Royal London hospital, Barts Health NHS Trust, United Kingdom
| | - Elaine Cole
- Centre for trauma sciences, Queen Mary University London, United Kingdom
| | - Parjam Zolfaghari
- Adult Critical care Unit, The Royal London hospital, Barts Health NHS Trust, United Kingdom; William Harvey Research Institute, Queen Mary University London, United Kingdom.
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18
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Williams BM, Mulima G, Charles A. Chest Trauma Management in Low- and Middle-Income Countries. Thorac Surg Clin 2022; 32:329-336. [PMID: 35961741 DOI: 10.1016/j.thorsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.
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Affiliation(s)
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina-Chapel Hill; Kamuzu Central Hospital, Lilongwe, Malawi.
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19
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Weinberg BJ, Roos R, van Aswegen H. Effectiveness of nonpharmacological therapeutic interventions on pain and physical function in adults with rib fractures during acute care: A systematic review and meta-analysis. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2022; 78:1764. [PMID: 35814044 PMCID: PMC9257723 DOI: 10.4102/sajp.v78i1.1764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/04/2022] [Indexed: 11/01/2022] Open
Affiliation(s)
- Beverley J. Weinberg
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ronel Roos
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- The Wits – JBI Centre for Evidenced-Based Practice: A Joanna Briggs Institute Affiliated Group, Johannesburg, South Africa
| | - Heleen van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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20
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Abdolrahimzadeh Fard H, Mahmudi-Azer S, Abdulzahraa Yaqoob Q, Sabetian G, Iranpour P, Shayan Z, Bolandparvaz S, Abbasi HR, Aminnia S, Salimi M, Mahmoudi MM, Paydar S, Borazjani R, Taheri Akerdi A, Zare M, Shayan L, Sasani M. Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims. Chin J Traumatol 2022; 25:170-176. [PMID: 35101294 PMCID: PMC8769602 DOI: 10.1016/j.cjtee.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/26/2021] [Accepted: 12/15/2021] [Indexed: 02/04/2023] Open
Abstract
PROPOSE In this study, we re-assessed the criteria defined by the radiological society of North America (RSNA) to determine novel radiological findings helping the physicians differentiating COVID-19 from pulmonary contusion. METHODS All trauma patients with blunt chest wall trauma and subsequent pulmonary contusion, COVID-19-related signs and symptoms before the trauma were enrolled in this retrospective study from February to May 2020. Included patients (Group P) were then classified into two groups based on polymerase chain reaction tests (Group Pa for positive patients and Pb for negative ones). Moreover, 44 patients from the pre-pandemic period (Group PP) were enrolled. They were matched to Group P regarding age, sex, and trauma-related scores. Two radiologists blindly reviewed the CT images of all enrolled patients according to criteria defined by the RSNA criteria. The radiological findings were compared between Group P and Group PP; statistically significant ones were re-evaluated between Group Pa and Group Pb thereafter. Finally, the sensitivity and specificity of each significant findings were calculated. The Chi-square test was used to compare the radiological findings between Group P and Group PP. RESULTS In the Group PP, 73.7% of all ground-glass opacities (GGOs) and 80% of all multiple bilateral GGOs were detected (p < 0.001 and p = 0.25, respectively). Single bilateral GGOs were only seen among the Group PP. The Chi-square tests showed that the prevalence of diffused GGOs, multiple unilateral GGOs, multiple consolidations, and multiple bilateral consolidations were significantly higher in the Group P (p = 0.001, 0.01, 0.003, and 0.003, respectively). However, GGOs with irregular borders and single consolidations were more significant among the Group PP (p = 0.01 and 0.003, respectively). Of note, reticular distortions and subpleural spares were exclusively detected in the Group PP. CONCLUSION We concluded that the criteria set by RSNA for the diagnosis of COVID-19 are not appropriate in trauma patients. The clinical signs and symptoms are not always useful either. The presence of multiple unilateral GGOs, diffused GGOs, and multiple bilateral consolidations favor COVID-19 with 88%, 97.62%, and 77.7% diagnostic accuracy.
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Affiliation(s)
- Hossein Abdolrahimzadeh Fard
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Salahaddin Mahmudi-Azer
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Golnar Sabetian
- Department of Intensive Care Medicine, Trauma Research Center, Shahid Rajaee (Emtiaz) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pooya Iranpour
- Department of Radiology, Medical Imaging Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shayan
- Department of Biostatistics, Trauma Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Bolandparvaz
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shiva Aminnia
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Mehdi Mahmoudi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Taheri Akerdi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masome Zare
- Trauma Intensive Care Unit, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Shayan
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammadreza Sasani
- Department of Radiology, Medical Imaging Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran,Corresponding author.
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21
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Kim D, Yoon SK, Lee GD, Kim DK. Nuss Procedure for Surgical Stabilization of Anterior Flail Chest with Mechanical Ventilation Weaning Failure: A Case Report. J Chest Surg 2022; 55:183-187. [PMID: 35193117 PMCID: PMC9005940 DOI: 10.5090/jcs.21.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022] Open
Abstract
Flail chest is a critical medical condition in which multiple segmentally fractured adjacent ribs cause paradoxical movement of the thoracic cage in patients with severe blunt trauma injury. Surgical stabilization is considered essential in patients who require mechanical ventilation. However, there is no consensus on which surgical procedure to choose among the various available techniques or when to perform surgery. We report the case of a patient with traumatic anterior flail chest due to bilateral multiple fractures of the ribs requiring surgical stabilization in whom weaning from mechanical ventilation had failed. The Nuss procedure using double bars with the bridge technique was performed for chest wall stabilization. The patient was weaned from mechanical ventilation on postoperative day 44 and she underwent bar removal on postoperative day 71. After extensive rehabilitation for multiple trauma, she was discharged successfully. The patient currently shows no recurrence of chest wall depression in outpatient follow-up.
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Affiliation(s)
- Donghee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Keun Yoon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Kushniruk A, Banks A, Melton GB, Porta CM, Tignanelli CJ. Barriers to and Facilitators for Acceptance of Comprehensive Clinical Decision Support System-Driven Care Maps for Patients With Thoracic Trauma: Interview Study Among Health Care Providers and Nurses. JMIR Hum Factors 2022; 9:e29019. [PMID: 35293873 PMCID: PMC8968578 DOI: 10.2196/29019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/04/2021] [Accepted: 12/19/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Comprehensive clinical decision support (CDS) care maps can improve the delivery of care and clinical outcomes. However, they are frequently plagued by usability problems and poor user acceptance. OBJECTIVE This study aims to characterize factors influencing successful design and use of comprehensive CDS care maps and identify themes associated with end-user acceptance of a thoracic trauma CDS care map earlier in the process than has traditionally been done. This was a planned adaptive redesign stage of a User Acceptance and System Adaptation Design development and implementation strategy for a CDS care map. This stage was based on a previously developed prototype CDS care map guided by the Unified Theory of Acceptance and Use of Technology. METHODS A total of 22 multidisciplinary end users (physicians, advanced practice providers, and nurses) were identified and recruited using snowball sampling. Qualitative interviews were conducted, audio-recorded, and transcribed verbatim. Generation of prespecified codes and the interview guide was informed by the Unified Theory of Acceptance and Use of Technology constructs and investigative team experience. Interviews were blinded and double-coded. Thematic analysis of interview scripts was conducted and yielded descriptive themes about factors influencing the construction and potential use of an acceptable CDS care map. RESULTS A total of eight dominant themes were identified: alert fatigue (theme 1), automation (theme 2), redundancy (theme 3), minimalistic design (theme 4), evidence based (theme 5), prevent errors (theme 6), comprehensive across the spectrum of disease (theme 7), and malleability (theme 8). Themes 1 to 4 addressed factors directly affecting end users, and themes 5 to 8 addressed factors affecting patient outcomes. More experienced providers prioritized a system that is easy to use. Nurses prioritized a system that incorporated evidence into decision support. Clinicians across specialties, roles, and ages agreed that the amount of extra work generated should be minimal and that the system should help them administer optimal care efficiently. CONCLUSIONS End user feedback reinforces attention toward factors that improve the acceptance and use of a CDS care map for patients with thoracic trauma. Common themes focused on system complexity, the ability of the system to fit different populations and settings, and optimal care provision. Identifying these factors early in the development and implementation process may facilitate user-centered design and improve adoption.
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Affiliation(s)
| | - Alyssa Banks
- University of Minnesota, Minneapolis, MN, United States
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Carolyn M Porta
- School of Nursing, University of Minnesota, Minneapolis, MN, United States
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States
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23
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The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury. Injury 2022; 53:1073-1080. [PMID: 34625240 DOI: 10.1016/j.injury.2021.09.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 05/12/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury. METHODS Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality. RESULTS A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%). CONCLUSIONS Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.
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24
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Uebayashi A, Takanashi Y, Oka M, Mizuno K, Kawase A, Funai K. Placement of
KANI
® plate inside the chest wall for rib fixation: Prevention for organ injuries caused by crossed rib edges and plate claws. Respirol Case Rep 2022; 10:e0914. [PMID: 35251663 PMCID: PMC8882854 DOI: 10.1002/rcr2.914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Abstract
The claw‐type titanium plate has been successfully applied to manage a flail chest. However, rare and life‐threatening organ injury occurs due to an insufficient claw bend. We report an ingenuity of surgical fixation using KANI® plates (USCI Japan, Tokyo, Japan) in a flail chest. A 60‐year‐old man with a severe flail chest underwent a surgical rib fixation. He had multiple rib fractures accompanied by dislocation and protruding crossed rib edges; we assumed a possibility of lung injury during a standard procedure in which the KANI® plates would be placed from outside the chest wall. Therefore, we placed KANI® plates inside the chest wall to ensure sufficient claw bend and to cover crossed rib edges to prevent organ injuries. We propose that our new ingenuity provides a safe and tight rib fixation in rib fractures with protruding crossed rib edges which the standard method cannot flatten.
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Affiliation(s)
- Asuka Uebayashi
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
| | - Yusuke Takanashi
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
| | - Mikako Oka
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
| | - Kiyomichi Mizuno
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
| | - Akikazu Kawase
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
| | - Kazuhito Funai
- First Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan
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25
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Improved Fixation Stability of a Dedicated Rib Fixation System in Flail Chest: A Retrospective Study. Medicina (B Aires) 2022; 58:medicina58030345. [PMID: 35334521 PMCID: PMC8955880 DOI: 10.3390/medicina58030345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Flail chest typically results from major trauma to the thoracic cage and is accompanied by multiple rib fractures. It has been well documented that surgical fixation of rib fractures can decrease both morbidity and mortality rates. This study aimed to evaluate the effectiveness of a dedicated APS Rib Fixation System, which features a pre-contoured design based on anatomical rib data of the Asian population. Materials and Methods: We reviewed 43 consecutive patients, who underwent surgical stabilization for flail chest with the traditional Mini bone plate (n = 20), APS plate (n = 13), or Mini + APS (n = 10). Demographic and injury variables were documented. We used X-ray radiography to determine plate fractures and screw dislocations after surgical fixation. Results: No statistical differences were noted in the demographic or injury variables. APS plates demonstrated fewer cases of plate fractures and screw dislocations than Mini plates (OR = 0.091, p = 0.008). Conclusions: The pre-contoured design of the APS plate demonstrated a superior rib implant failure rate as compared to the traditional Mini bone plate. Our study indicates that the APS plate may serve as an effective surgical tool for the treatment of flail chest.
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26
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Arborelius UP, Rocksén D, Gustavsson J, Günther M. Pulmonary hypoxia and venous admixture correlate linearly to the kinetic energy from porcine high velocity projectile behind armor blunt trauma. Exp Lung Res 2021; 47:323-333. [PMID: 34278891 DOI: 10.1080/01902148.2021.1950869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose. Behind armor blunt trauma (BABT) is a non-penetrating injury caused by the rapid deformation of body armor, by a projectile, which may in extreme circumstances cause death. The understanding of the mechanisms is still low, in relation to what is needed for safety threshold levels. High velocity projectile BABT causes immediate and severe hypoxia by increased venous admixture (Q's/Q't), but it is not known whether the level of hypoxia correlates to the kinetic energy (Ek) of the projectile.Materials and Methods. We constructed a 65 mm BABT-simulator to measure the Ek absorbed by the thorax. The simulator was validated to 7.62 mm high velocity BABT (swine with removed organs) for 7.62 mm (n = 7) and 65 mm (n = 12). Physiological measurements during 60 minutes were performed in 40 anesthetized swine in groups control (n = 9), 7.62 mm (n = 7), 65 mm weight variation (n = 24), 65 mm speed variation (n = 12, included in the weight variation group). New calculations were done for a previously studied group of 7.62 mm with backing (n = 9).Results. 65 mm BABT simulation and 7.62 mm BABT had similar back-face signatures (24 mm), and maximum thoracic impression speed (24-34 m/s). Back-face signatures correlated linearly to Ek (R2=0.20). Rib fractures had a 50% likelihood at back-face signature 23.0 mm (95% CI 18.5 to 29.0 mm, area under ROC curve 0.93). Ek correlated linearly to pO2 (R2=0.34, p = 0.0026) and venous admixture (R2=0.37, p = 0.0046). The extrapolated Ek at 5 minutes for pO2=0 kPa was 587 J and for venous admixture = 100% 574 J.Conclusions. Hypoxia and venous admixture correlated linearly to Ek, allowing for a calculated predicted lethal Ek to ≥574 J, which should be verified in survival studies. Lethality predictions from lung physiology is an alternative to clay impressions and may facilitate the development of ballistic safety equipment and new BABT safety criteria.Supplemental data for this article is available online at https://doi.org/10.1080/01902148.2021.1950869 .
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Affiliation(s)
- Ulf P Arborelius
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - David Rocksén
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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27
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Owattanapanich N, Lewis MR, Benjamin ER, Jakob DA, Demetriades D. surgical rib fixation in isolated flail chest improves survival. Ann Thorac Surg 2021; 113:1859-1865. [PMID: 34214544 DOI: 10.1016/j.athoracsur.2021.05.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/20/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study aimed to examine the impact of fixation in isolated flail chest patients. METHODS All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an outside hospital, had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation. RESULTS Of 287,947 patients with rib fractures, there were 12,110 (4.2%) patients with flail chest. After exclusion, 5,293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%) and 4,718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, p= 0.001). On multivariate analysis, rib fixation was associated with improved mortality (OR 0.355, p= 0.002). The timing of operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days). CONCLUSIONS Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.
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Affiliation(s)
- Natthida Owattanapanich
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Meghan R Lewis
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Elizabeth R Benjamin
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Dominik A Jakob
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Demetrios Demetriades
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA..
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28
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Daskal Y, Paran M, Korin A, Soukhovolsky V, Kessel B. Multiple rib fractures: does flail chest matter? Emerg Med J 2021; 38:496-500. [PMID: 33986019 DOI: 10.1136/emermed-2020-210999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/02/2021] [Accepted: 05/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures. METHODS This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality. RESULTS The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest. CONCLUSION In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.
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Affiliation(s)
- Yaakov Daskal
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Maya Paran
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | | | | | - Boris Kessel
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
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29
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Uhlich R, Kerby JD, Bosarge P, Hu P. Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures. Trauma Surg Acute Care Open 2021; 6:e000600. [PMID: 33981859 PMCID: PMC8076940 DOI: 10.1136/tsaco-2020-000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/04/2020] [Accepted: 04/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Rib fractures are common among trauma patients and may result in significant morbidity and mortality. There are numerous treatment options, but ideal management is unclear. Delivery of local anesthetic via an analgesia catheter for continuous intercostal nerve blockade offers an attractive potential option for management of patients with rib fractures. Methods We performed a single-center, retrospective case-control analysis of trauma patients with multiple rib fractures from 2016 to 2018, comparing patients managed with continuous intercostal nerve blockade with standard care. Matching was performed in a 2:1 ratio by Injury Severity Score, age, and gender. Respiratory morbidity potentially secondary to rib fractures, including unplanned intubation, failure of extubation, need for tracheostomy, pneumonia, or mortality, were all identified and included. Potential complications due to catheter insertion were identified to be recorded. The primary outcome of interest was 30-day hospital-free days. Results Nine hundred and thirty-three patients were eligible for analysis, with 48 managed using intercostal blockade compared with 96 matching controls. No complications of intercostal blockade were identified during the study period. Controls demonstrated fewer rib fractures (6.60±4.11 vs. 9.3±3.73, p=0.001) and fewer flail segments (0.8±1.76 vs. 2.0±2.94, p=0.02). Those managed with intercostal blockade demonstrated significantly more 30-day hospital-free days (15.9±6.43 vs. 13.2±9.94, p=0.048), less incidence of pneumonia (4.2% vs. 16.7%, p=0.03), and lower hospital mortality (2.1% vs. 13.5%, p=0.03). When adjusting for number of rib fractures and number of flail segments, use of continuous intercostal nerve blockade was significantly associated with lower hospital mortality (OR 0.10; 95% CI 0.01 to 0.91), pneumonia (OR 0.15; 95% CI 0.03 to 0.76), or need for tracheostomy (OR 0.23; 95% CI 0.06 to 0.83). Discussion The addition of continuous intercostal nerve blockade may help to improve outcomes in patients with multiple rib fractures compared with standard care alone. Level of evidence Therapeutic/care management; level IV.
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Affiliation(s)
- Rindi Uhlich
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Patrick Bosarge
- Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
| | - Parker Hu
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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30
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Riojas C, Cunningham KW, Green JM, Sachdev G, Ross SW, Lauer CW, Thomas BW. Attention to detail: A dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes. Am J Surg 2021; 223:410-416. [PMID: 33814108 DOI: 10.1016/j.amjsurg.2021.03.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes. METHODS A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge. RESULTS 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days. CONCLUSION Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Christina Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - John M Green
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - Gaurav Sachdev
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - Cynthia W Lauer
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States
| | - Bradley W Thomas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, NC.1000 Blythe Boulevard, Charlotte, NC, 28203, United States.
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Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience. Injury 2021; 52:235-242. [PMID: 32958343 DOI: 10.1016/j.injury.2020.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
PURPOSES Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes. METHODS A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21. RESULTS Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p<0.001 in lateral flail chest and p<0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches. CONCLUSIONS Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.
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Noninvasive ventilation with a helmet in patients with acute respiratory failure caused by chest trauma: a randomized controlled trial. Sci Rep 2020; 10:21489. [PMID: 33293689 PMCID: PMC7722864 DOI: 10.1038/s41598-020-78607-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 11/25/2020] [Indexed: 02/03/2023] Open
Abstract
Noninvasive ventilation (NIV) is beneficial in acute respiratory failure (ARF) caused by chest trauma; however, NIV-related complications affect the efficacy. We evaluated whether NIV with helmet decreases the incidence of complications and improves its effects in a single center. Patients with ARF after chest trauma were randomized to receive NIV with helmet or face mask. The primary outcome was the rate of NIV-related complications. Secondary outcomes were PaO2/FiO2, patient’s tolerance, intubation rate, length of intensive care unit (ICU) stay, and ICU mortality. The trial was terminated early after an interim analysis with 59 patients. The incidence of complications was lower in the helmet group [10% (3/29) vs 43% (13/30), P = 0.004], and PaO2/FiO2s were higher at 1 h and at the end of NIV (253.14 ± 64.74 mmHg vs 216.06 ± 43.86 mmHg, 277.07 ± 84.89 mmHg vs 225.81 ± 63.64 mmHg, P = 0.013 and 0.012) compared with them in face mask group. More patients reported excellent tolerance of the helmet vs face mask after 4 h of NIV [83% (24/29) vs 47% (14/30), P = 0.004] and at the end of NIV [69% (20/29) vs 30% (9/30), P = 0.03]. Differences in intubation rate, ICU stay, and mortality were non-significant (P = 0.612, 0.100, 1.000, respectively). NIV with helmet decreased NIV-related complications, increased PaO2/FiO2, and improved tolerance compared with NIV with face mask in patients with chest trauma. Trial registration: Registered in the Chinese Clinical Trial Registry (ChiCTR1900025915), a WHO International Clinical Trials Registry Platform (http://www.chictr.org.cn/searchprojen.aspx).
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Mazcuri M, Ahmad T, Abid A, Thapaliya P, Ali M, Ali N. Pattern and Outcome of Thoracic Injuries in a Busy Tertiary Care Unit. Cureus 2020; 12:e11181. [PMID: 33133801 PMCID: PMC7593122 DOI: 10.7759/cureus.11181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Thoracic traumas are one of the most commonly encountered injuries in the emergency room. They range from blunt chest injuries due to road traffic accidents to penetrating chest injuries. Immediate medical and surgical interventions are essential to improve the outcome. This study was conducted to assess the pattern of thoracic trauma presenting to the emergency room, their outcome and factors contributing to it. METHODS This prospective, observational, cross-sectional study was conducted in the Department of Thoracic Surgery, Jinnah Post Graduate Medical Center, Karachi from January 1 until July 31, 2020, with institutional ethical approval. Patients age ≥12 years presenting with traumatic thoracic injury with or without associated injuries were included. Characteristics of their injuries and management outcome were studied. All data was processed through Statistical Package for Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY, USA). RESULTS A total of 199 patients were included; 154 (77.4%) patients were male and 45 (22.6%) patients were female. The most common age group presenting with trauma was the middle age (30-60 years), which included 101 (50.8%) patients. Out of the total, 126 (63.3%) had blunt chest injuries and 73 (36.6%) had penetrating chest injuries. Road traffic accidents were the most common cause of blunt chest injuries seen in 83 (65.8%) patients, whereas gunshot was the most common mode of penetrating chest injuries encountered in 41 (56.2%) cases. Tube thoracostomies were performed in 166 (83.4%) patients and thoracotomies in seven (3.51%) patients. Out of the total, 57 (28.6%) patients required mechanical ventilation and it was associated with blunt trauma, hemothorax, rib fracture, abdominal and head injuries (p ≤0.05). Mortality was seen in 22 (11.1%), which was associated with hemothorax, head injuries, mechanical ventilation and severe blood loss (p ≤0.05). CONCLUSION Traumatic thoracic injuries are a preventable cause of mortality. Blunt chest injuries are more common than penetrating chest injuries. Proper implementation of public safety measures ensures less frequent and severe outcomes. Emergency department team and specialized thoracic surgeons must come together to manage these critical patients with utmost care.
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Affiliation(s)
- Misauq Mazcuri
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Tanveer Ahmad
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Ambreen Abid
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | | | - Mansab Ali
- General Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Nadir Ali
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
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Rocksén D, Arborelius UP, Gustavsson J, Günther M. Severe, transient pulmonary ventilation-perfusion mismatch in the lung after porcine high velocity projectile behind armor blunt trauma. Exp Lung Res 2020; 46:271-282. [DOI: 10.1080/01902148.2020.1797246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- David Rocksén
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P. Arborelius
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Çınar HU, Çelik B. Comparison of Surgical Stabilization Time in Patients with Flail Chest. Thorac Cardiovasc Surg 2020; 68:743-751. [PMID: 32634836 DOI: 10.1055/s-0040-1713661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Hüseyin Ulaş Çınar
- Department of Thoracic Surgery, Medicana International Samsun Hospital, Samsun, Turkey
| | - Burçin Çelik
- Department of Thoracic Surgery, Medical School, Ondokuz Mayıs University, Samsun, Turkey
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Lii TR, Aggarwal AK. Comparison of intravenous lidocaine versus epidural anesthesia for traumatic rib fracture pain: a retrospective cohort study. Reg Anesth Pain Med 2020; 45:628-633. [PMID: 32503863 DOI: 10.1136/rapm-2019-101120] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/11/2020] [Accepted: 05/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Effective analgesia is essential in managing traumatic rib fractures. Intravenous lidocaine (IVL) is effective in treating perioperative pain, acute pain in the emergency department, cancer pain in hospice, and outpatient chronic neuropathic pain. Our study examined the associations between IVL versus epidural analgesia (EA) and pain for the treatment of acute rib fracture in the inpatient setting. METHODS We performed a retrospective study involving adults admitted to an academic level I trauma center from June 1, 2011 to June 1, 2016 with consults to the pain service for acute rib fracture pain. Eighty-nine patients were included in the final analysis (54 IVL and 35 EA patients). Both groups had usual access to opioid medications. The primary outcome was absolute change in numeric pain scores during 0-24 and 24-48 hours after initiating IVL or EA, compared with baseline. Secondary outcomes include opioid consumption, incentive spirometry, supplemental oxygens, pneumonia, endotracheal intubation and length of hospital stay. RESULTS Numeric pain scores differed at baseline (mean 5.6 for IVL vs 4.5 for EA, p=0.01), while age, injury severity, and number of fractured ribs were similar. IVL and EA were associated with similar reductions in numeric pain scores within 0-24 and 24-48 hours (mean -2.9 for IVL vs -2.3 for EA during both periods, p=0.19 and p=0.17 respectively) . There was greater non-neuraxial opioid consumption with IVL compared with EA (98.6 vs 22.3 mg morphine equivalents (MME) at 0-24 hours, p=0.0005; 105.6 vs 18.9 MME at 24-48 hours, p<0.0001). When epidural opioids were analyzed, the EA group was exposed to higher total MME at 0-24 hours (655.2 vs 98.6 MME, p<0.0001) and 24-48 hours (586 vs 105.6 MME, p=0.0001), suggesting an opioid sparing effect of IVL. CONCLUSION Our results suggest that IVL is similar to EA in numeric pain score reduction, and that IVL may have an opioid sparing effect when taking neuraxial opioids into account. IVL may be an effective alternative to epidurals for the treatment of rib fracture pain. It should be considered for patients who have contraindications to epidurals or are unable to receive an epidural in a timely manner.
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Affiliation(s)
- Theresa Riki Lii
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Anuj Kailash Aggarwal
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
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Cunningham BP, Bosch L, Swanson D, McLemore R, Rhorer AS, Parikh HR, Albersheim M, Ortega G. The floating flail chest: Acute management of an injury combination of the floating shoulder and flail chest. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491719899076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background/purpose: The combination of ipsilateral floating shoulder and flail chest is a unique injury pattern that has not been previously described in the literature. We termed the injury pattern floating flail chest (FFC). The purpose of this study was to evaluate the effect of operative treatment of the shoulder girdle component to overall hospital length of stay (LOS). Methods: Forty-one patients were enrolled between two level I trauma centers identifying with a combination ipsilateral floating shoulder and flail chest injury, 23 treated with operative stabilization and 18 treated non-operatively. This retrospective cohort study evaluated the overall LOS and intensive care unit (ICU) days. Results: The operative group had decreased overall LOS (10.1 vs. 19.8 days, p = 0.02) and decreased ICU days (3.4 vs. 10.3, p = 0.04). Conclusion: This study describes a unique injury pattern that combines the floating shoulder and flail chest, FFC. Our study suggests that operative treatment of the shoulder girdle may decrease both overall LOS and ICU days in patients with FFC.
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Affiliation(s)
- Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Liam Bosch
- Stanford Medicine Orthopaedic Residency, Stanford, CA, USA
| | - David Swanson
- Sonoran Orthopaedic Trauma Surgeons, Scottsdale, AZ, USA
| | - Ryan McLemore
- Clinical Outcomes and Data Engineering (CODE) Technology, Phoenix, AZ, USA
| | | | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Gilbert Ortega
- Sonoran Orthopaedic Trauma Surgeons, Scottsdale, AZ, USA
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Guo Q, Zhang J, Cai K, Zhang J. Combining the use of Nuss procedure and rib fixation for severe flail chest: a case report. BMC Surg 2020; 20:87. [PMID: 32370809 PMCID: PMC7201783 DOI: 10.1186/s12893-020-00747-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 04/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe flail chest is a life-threatening situation. The Nuss procedure is a new effective treatment for severe flail chest patients who cannot be weaned from prolonged mechanical ventilation in the last few years. However, the procedure is not suitable when there are multiple fractures in both the anterior and lateral chest walls. Here, we reported a rare case of severe flail chest in a patient who suffered multiple fractures in both the anterior and lateral chest walls in a traffic accident. CASE PRESENTATION A 49-year-old patient suffered severe flail chest by a steering wheel in a traffic accident with multiple fractures in both the anterior and lateral chest walls. In the beginning, the patient was administrated with mechanical ventilation because of acute respiratory distress syndrome (ARDS) for more than 1 week. Then the patient suffered from a severe lung infection and decreased blood oxygen saturation. After a multidiscipline discussion (MDT), three rib fixation plates were first used to rebuild the stability of lateral chest walls, then two Nuss bars were inserted to eliminate paradoxical movement in the anterior chest wall. Finally, the patient recovered smoothly after the combining procedure. CONCLUSIONS Severe flail chest patients with both the anterior and lateral chest walls after trauma are in a life-threatening situation, and require an appropriate procedure to get out of danger in time. Rib fixation is an effective treatment when the fractured sites are few and the fractured area is small. The Nuss procedure is a new effective method for severe flail chest with multiple fractures in an anterior chest wall, which is also a minimally invasive and short time-consuming procedure. However, it does not suitable for the patient with multiple fractures in lateral chest walls. Combining the use of Nuss procedure and rib fixation can solve severe flail chest with multiple ribs and sternum fractures in both the anterior and lateral chest walls, and the outcome of this procedure is satisfying in the present rare case.
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Affiliation(s)
- Quanwei Guo
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, No.1333, Xinhu Road, Bao'an District, Shenzhen, 518101, Guangdong, China.,Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jinghui Zhang
- Department of Thoracic Surgery, Wuwei People's Hospital, Wuwei, 733000, Gansu, China
| | - Kaican Cai
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jianhua Zhang
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, No.1333, Xinhu Road, Bao'an District, Shenzhen, 518101, Guangdong, China.
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Ingoe HM, Eardley W, McDaid C, Rangan A, Lawrence T, Hewitt C. Epidemiology of adult rib fracture and factors associated with surgical fixation: Analysis of a chest wall injury dataset from England and Wales. Injury 2020; 51:218-223. [PMID: 31690496 DOI: 10.1016/j.injury.2019.10.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chest wall trauma is commonly seen in patients admitted with both high and low-energy transfer injury. Whilst often associated with other injuries, it is also seen in isolation following simple falls in the older patient. Fixation of the chest wall grows in popularity as part of optimising patient care, particularly in terms of critical care stay. There is currently no description of the epidemiology of these injuries at a national level; nor has there been identification of factors that predict which of these patients undergoes surgery. METHODS The United Kingdom Trauma Audit & Research Network (TARN) database was analysed for the period April 2016 to 30th May 2017 for all adult patients presenting with a rib or sternal fracture. Characteristics of the population were described and a binary logistic regression model constructed to explore the influences of several explanatory variables on whether fixation was performed. RESULTS Of 16,638 patients with chest wall trauma, 402 underwent fixation. Most chest wall injury patients were admitted under three specialties (orthopaedics (19.1%), emergency medicine (16.6%) and general surgery (17.7%)). The odds of fixation in unilateral flail chest was 107.51 (p <0.0001), in bilateral flail or combined complexsternal fracture 47.63 (p = 0.007) and in 3 or more non-flail ribs 15.62 (p<0.0001) when compared to less than three non-flail rib fractures. The odds of fixation was higher in an MTC (p<0.0001) compared to a non-specialist hospital. The odds of fixation was higher in older patients (1.02, p<0.0001) and the more severely injured (1.02, p<0.0001). CONCLUSION There is considerable variation nationally in the management of chest wall trauma. Injury type, patient age and care setting contribute to decision making in fracture fixation. This unique national dataset characterises for the first time the nature of contemporary chest wall trauma management and should help inform the design of future research on this topic.
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Affiliation(s)
- Helen Ma Ingoe
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW.
| | - William Eardley
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW.
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD.
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW; NDORMS, University of Oxford, research supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).
| | - Tom Lawrence
- Trauma and Audit Research Network, Manchester Medical Academic Health Sciences Centre, University of Manchester, The Mayo Building, Salford Royal Hospital, Salford M6 8HD.
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD.
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Zahran MR, Elwahab AAEMA, El Nasr MMA, El Heniedy MA. Evaluation of the predictive value of thorax trauma severity score (TTSS) in thoracic-traumatized patients. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-0015-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background
Thorax trauma severity score (TTSS) combines patient-related parameters with the anatomical and physiological parameters, and it can be easily calculated in the emergency room. The validity of this score in the Egyptian population has not been tested; therefore, the objective of this study was to evaluate the prognostic role of TTSS to predict the outcome of thoracic trauma in the Egyptian patients in two centers.
Results
The study included 284 male patients (94.7%) with a mean age of 41 years. Fifty-six patients (18.7%) had conservative management, 216 had morbidity (72%), and 28 patients died (9.3%). One hundred forty-eight patients (49.3%) had a thoracostomy tube, and thoracotomy was required in 4 patients (1.3%). Respiratory rate above 20 cycles/min at admission was associated with mortality (n = 28 (9.3%); p < 0.001). One hundred thirty-six patients had TTSS between 0 and 5 points; 56 of them were discharged and 80 of them were admitted to the inpatient ward with a good prognosis. Twenty-four patients had TTSS between 21 and 25 points; all the 24 patients had a fatal prognosis. A cut-off value of 7 points or more of TTSS was 100% sensitive and 97.73% specific to poor and fatal prognosis, and it was significantly associated with acute respiratory distress syndrome and the need for mechanical ventilation (n = 64; p < 0.001; AUC = 0.998).
Conclusion
The outcome of thoracic trauma patients could be predicted based on the thorax trauma severity score. A score of 7 points or above was associated with increased morbidity, and a score of 20 points or above predicted a fatal prognosis and prolonged mechanical ventilation.
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Kim KT, Chang SW. An unexpected fracture of a titanium rib plate in a patient with traumatic brain injury. Trauma Case Rep 2019; 24:100254. [PMID: 31872025 PMCID: PMC6911856 DOI: 10.1016/j.tcr.2019.100254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/23/2019] [Accepted: 09/19/2019] [Indexed: 12/02/2022] Open
Abstract
Surgical stabilization of rib fractures has been accepted and successfully performed for the management of patients with multiple rib fractures. Several types of devices, such as titanium bar, plate, and screws, are used for rib stabilization. Titanium devices provide a strong support for rib fixation and chest wall reconstruction and are rarely associated with complications. Herein, we report an unusual case of mechanical failure associated with a broken titanium plate. A 47-year-old man was treated with surgical stabilization of rib fractures using titanium plates after blunt trauma leading to epidural hematoma and massive hemothorax. After decompressive craniectomy, bleeding control, and rib fixation for chest trauma, he developed hyperactive delirium, which was not well controlled. On the 17 day of operation, a chest radiograph showed a broken rib plate. Surgeons who perform surgical rib stabilization should be aware that titanium plates are vulnerable to breakage under some conditions, such as hyperactive delirium.
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Affiliation(s)
- Ki Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Republic of Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Republic of Korea
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Schulz-Drost S, Finkbeiner R, Lefering R, Grosso M, Krinner S, Langenbach A, DGU TT. Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU. Thorac Cardiovasc Surg 2019; 69:735-748. [DOI: 10.1055/s-0039-1700505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background Thorax trauma frequently occurs in which injuries to the bony chest, lung contusions (LCs), and others are diagnosed. The significance of this violation is described very differently and is mostly based on monocentric data.
Methods A retrospective analysis of the TraumaRegister DGU® (TR-DGU) dataset (Project 2014–062) was performed between 2009 and 2014 (injury severity score [ISS] ≥ 16, primary admission to a trauma center, no isolated traumatic brain injury). Patients with LC (Abbreviated Injury Scale [AIS] 3 + 4) were compared with the control group, and an analysis of different age groups was performed.
Results A total of 49,567 patients were included, thereunder 14,521 (29.3%) without relevant thoracic trauma (TT); 95.9% blunt traumas. 18,892 patients (38.1%) had LC and 14,008 (28.3%) had severe LC with AIS 3 + 4; thereunder 72.7% males. For severe LC, the average age was the lowest (44.7 ± 19.7 years) and ISS the highest (30.4 ± 12.1 points).Intubation, intensive care, (multi-) organ failure, sepsis, and extrathoracic injuries were most common in severe LC. Shock, chest tubes, further thoracic injuries, and patient death occurred most frequently in TT without LC.Younger patients showed a higher incidence of LC than the older ones; however, high patient age was a highly significant risk factor for the development of complications and poor outcome.
Conclusion Since LC was present in almost 40% of the severely injured and was related to higher morbidity, LC should be detected and managed at the earliest possible time. Proper follow-ups employing chest X-rays and computed tomography (CT) scans are recommended.
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Affiliation(s)
- Stefan Schulz-Drost
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
- Department of Trauma and Orthopedic Surgery, BG Hospital Unfallkrankenhaus Berlin GmbH, Berlin, Germany
| | - Rebekka Finkbeiner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Marco Grosso
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Krinner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Langenbach
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - the TraumaRegister DGU
- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU)
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Ahmad R, Bhatti DS, Bokhari MHT, Asad A. A University Hospital Based Study on Thoracic Trauma: Life Threatening Event, Its Etiology, Presentation, and Management. Cureus 2019; 11:e6306. [PMID: 31938598 PMCID: PMC6944145 DOI: 10.7759/cureus.6306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Thoracic injury is becoming an important cause of mortality in Pakistan, especially in the younger subset of population. The initial management of these injuries is essential as these patients can develop multiple complications, ultimately leading to death of the patients. MATERIALS AND METHODS This prospective observational study was carried out from January 2016 to December 2018 at the Department of Surgery, Holy Family Hospital, Rawalpindi Medical University, Pakistan. It included all the patients over 12 years of age who had thoracic trauma, who presented in the ED, and were admitted to the surgical ward and intensive care unit (ICU). Data were collected with the help of a pre-designed proforma. After relevant investigations and treatment, data were collected and analyzed through Statistical Package for Social Sciences (SPSS) for version 19. Nominal variables were reported as frequencies and percentages. RESULTS Out of a total of 330 patients, 188 (56.9%) suffered from blunt injuries whereas 142 (43%) had penetrating injuries. The most common cause of these injuries was road traffic accidents -- 105 (32%) followed by falls -- 23 (76%). Most of the injuries encountered were isolated pneumothorax -- 74 (22.4%) followed by rib fractures with pneumothorax -- 71 (21.5%). Tube thoracostomy was done in 189 cases (57.3%) whereas 94 (28.5%) patients were managed conservatively. Complications were seen in 117 patients (35.4%). Out of these 117 cases, death was the major complication - 30 (25.6%) followed by bronchopleural fistula - 24 (20.5%) and empyema thoracis - 22 (18.8%). CONCLUSION Road traffic accidents are a major cause of thoracic injuries in our setting. Tube thoracostomy is the most commonly used treatment modality. Mortality rate is high in the patients with thoracic injuries.
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Affiliation(s)
| | - Dujanah S Bhatti
- Plastic Surgery, Holy Family Hospital, Rawalpindi Medical College, Rawalpindi, PAK
| | | | - Ayesha Asad
- Anatomy, Quetta Institute of Medical Sciences, Quetta, PAK
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Schulz-Drost S, Ekkernkamp A, Stengel D. [Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. Unfallchirurg 2019; 121:605-614. [PMID: 30073550 DOI: 10.1007/s00113-018-0532-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.
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Affiliation(s)
- S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland.
| | - A Ekkernkamp
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - D Stengel
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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Extracorporeal Carbon Dioxide Removal in the Management of Complex Bilateral Flail Chest Injury. ASAIO J 2019; 65:e75-e77. [DOI: 10.1097/mat.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Shih KS, Truong TA, Hsu CC, Hou SM. Biomechanical investigation of different surgical strategies for the treatment of rib fractures using a three-dimensional human respiratory model. ACTA ACUST UNITED AC 2019; 64:93-102. [PMID: 29095691 DOI: 10.1515/bmt-2017-0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/09/2017] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Kao-Shang Shih
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC.,College of Medicine, Fu Jen Catholic University, Taipei 242, Taiwan, ROC
| | - Thanh An Truong
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei 106, Taiwan, ROC
| | - Ching-Chi Hsu
- Graduate Institute of Applied Science and Technology, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Taipei 106, Taiwan, ROC
| | - Sheng-Mou Hou
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC
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Abstract
INTRODUCTION Flail chest is considered a highly morbid condition with reported mortality ranging from 10 to 20%. It is often associated with other severe injuries, which may complicate management and interpretation of outcomes. The physiologic impact and prognosis of isolated flail chest injury is poorly defined. METHODS This is a National Trauma Databank study. All patients from 1/2007 to 12/2014 admitted with flail chest were extracted. Patients with head or abdominal AIS ≥3, dead on arrival, or transferred, were excluded. Primary outcome was mortality; secondary outcomes were need for mechanical ventilation and pneumonia. RESULTS Of the 1,047,519 patients with blunt chest injury, 14,718 (1.4%) patients presented with flail chest, and 8098 (0.77%) met inclusion criteria. The most commonly associated intrathoracic injuries were hemothorax (57.9%) and lung contusions (63.0%), while sternal fracture (8.8%) and cardiac contusion (2.5%) were less common. In total, 29.8% of patients required mechanical ventilation, and 11.2% developed pneumonia. Overall mortality was 5.6%. On multivariable analysis, age >65 and need for mechanical ventilation were independent risk factors for mortality (OR 6.02, 3.75, respectively, p < 0.001). Independent predictors for mechanical ventilation included cardiac or pulmonary contusion and sternal fractures (OR 3.78, 2.38, 2.29, respectively, p < 0.001). Need for mechanical ventilation was an independent predictor of pneumonia (OR 13.18, p < 0.001). CONCLUSIONS Mortality in isolated flail chest is much lower than previously reported. Fewer than 30% of patients require mechanical ventilation. Need for mechanical ventilation, however, is independently associated with mortality and pneumonia. Age >65 is an independent risk factor for adverse outcomes, and these patients may benefit by more aggressive monitoring and treatment.
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Fawcett K, Gerber N, Iyer S, De Angulo G, Pusic M, Mojica M. Common Conditions Requiring Emergency Life Support. Pediatr Rev 2019; 40:291-301. [PMID: 31152101 DOI: 10.1542/pir.2017-0331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kelsey Fawcett
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Nicole Gerber
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Shweta Iyer
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Guillermo De Angulo
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | | | - Michael Mojica
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY.,Department of Emergency Medicine, Bellevue Hospital Center, New York, NY
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A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. J Surg Res 2019; 242:223-230. [PMID: 31100568 DOI: 10.1016/j.jss.2019.04.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 02/19/2019] [Accepted: 04/03/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Flail chest (FC) is known to account for high mortality and morbidity and is typically treated with conservative care. Operative fixation of FC has been advocated as an alternative treatment choice. This prospective randomized controlled trial aims to compare surgical and nonsurgical management of FC in patients with severe polytrauma. METHODS Severe polytrauma patients with FC admitted between January 2015 and July 2017 to our trauma center were investigated. The enrolled patients were randomly assigned to the surgical or nonsurgical group. Basic characteristics of injury and clinical outcomes were compared. RESULTS Fifty patients entered final analysis, with 25 patients in each group. Operative rib fixation was associated with shorter duration of mechanical ventilation (7 d [interquartile range {IQR} 6-10] versus 9 d [IQR 7-12], P = 0.012), shorter ICU stay (10 d [IQR 7-12] versus 12 d [IQR 9-15], P = 0.032), lower risk of adult respiratory distress syndrome (28% versus 60%, P = 0.045), pneumonia (48% versus 80%, P = 0.038), and thoracic deformity (8% versus 36%, P = 0.037) and less pain while coughing (pain score 6 [IQR 3-8] versus 8 [IQR 4-9], P = 0.029) and deep breathing (pain score 5 [IQR 3-9] versus 7 [IQR 3-9], P = 0.038). Subgroup analysis was conducted by presence of pulmonary contusion. Shorter time on the ventilator use and ICU stay associated with rib surgery was not observed in patients with pulmonary contusion. CONCLUSIONS This study reveals that surgical rib fixation may provide some critical care benefits for severe polytrauma patients with FC, including less medical resource use and lower risk of complications. Further studies should be designed to optimally identify patients who are most likely to benefit from this surgery.
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He Z, Zhang D, Xiao H, Zhu Q, Xuan Y, Su K, Liao M, Tang Y, Xu E. The ideal methods for the management of rib fractures. J Thorac Dis 2019; 11:S1078-S1089. [PMID: 31205765 DOI: 10.21037/jtd.2019.04.109] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Zhe He
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Dongsheng Zhang
- Department of Thoracic Surgery, Shijiazhuang Third Hospital, Shijiazhuang 050011, China
| | - Haiping Xiao
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Qihang Zhu
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Yiwen Xuan
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Kai Su
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Ming Liao
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Yong Tang
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Enwu Xu
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China.,Southern Medical University, Guangzhou 510515, China
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