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Schreyer C, Schulz-Drost S, Markewitz A, Breuing J, Prediger B, Becker L, Spering C, Neudecker J, Thiel B, Bieler D. Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02556-1. [PMID: 38888790 DOI: 10.1007/s00068-024-02556-1] [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: 02/19/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.
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Affiliation(s)
- C Schreyer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany
| | - S Schulz-Drost
- Department of Trauma Surgery, Schwerin Helios Hospital, Schwerin and Department of Trauma and Orthopaedic Surgery, Schwerin, Germany
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - A Markewitz
- German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
| | - J Breuing
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - B Prediger
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - L Becker
- Department of Trauma Surgery, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - C Spering
- Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, Göttingen University Medical Centre, Göttingen, Germany
| | - J Neudecker
- Department of Surgery, Berlin Charité Hospital, Campus Charité Mitte and Campus Virchow, Berlin, Germany
| | - B Thiel
- Department of Thoracic Surgery, Klinikum Westfalen Knappschaft, Lünen, Germany
| | - D Bieler
- Department for Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.
- Department for Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University, Duesseldorf, Germany.
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Al Wahaibi H, Al Salmi A, Al Reesi A, Al Shamsi M. Comparison of Observation Alone Versus Interventional Procedures in Hemodynamically Stable Patients With Pneumothorax: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58385. [PMID: 38756278 PMCID: PMC11097702 DOI: 10.7759/cureus.58385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Several studies indicate that observation alone is sufficient for the management of stable pneumothorax. To compare clinical efficacy, tolerability, and safety outcomes for treating hemodynamically stable adult patients with pneumothorax, the present review compared observation alone versus interventional procedures. We searched PubMed and Google Scholar from inception until June 24, 2020, for randomized controlled trials (RCTs) comparing observational therapy with conventional therapy for the treatment of adult pneumothorax. The pediatric age group and patients with tension pneumothorax were not included. Four hundred and forty-six patients were enrolled in three RCTs. The failure rate (relative risk (RR) 4.30; 95% CI = 0.23-81.82, p = 0.33) and mortality (RR 1.01; 95% CI = 0.31-3.33, p = 0.98) of observation were comparable to those of the chest tube. Chest tube and observation both carried comparable risks of complications, including tension pneumothorax and empyema (RR 3.15; 95% CI = 0.67-1) and (RR 1.55; 95% CI = 0.21-11.56, p = 0.67), respectively. Between chest tubes and observation, there was no statistically significant difference in the duration of hospital stay. We conclude that observation is as safe and effective at treating adult patients with stable pneumothorax as a chest tube.
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Griffard J, Kodadek LM. Management of Blunt Chest Trauma. Surg Clin North Am 2024; 104:343-354. [PMID: 38453306 DOI: 10.1016/j.suc.2023.09.007] [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: 03/09/2024]
Abstract
Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.
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Affiliation(s)
- Jared Griffard
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building 310, New Haven, CT 06510, USA
| | - Lisa M Kodadek
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building 310, New Haven, CT 06510, USA.
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Bettoni G, Gheda S, Altomare M, Cioffi SPB, Ferrazzi D, Cazzaniga M, Bonacchini L, Cimbanassi S, Aseni P. Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:548. [PMID: 38674194 PMCID: PMC11051943 DOI: 10.3390/medicina60040548] [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: 02/28/2024] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024]
Abstract
Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.
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Affiliation(s)
- Giuseppe Bettoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Silvia Gheda
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, 00185 Rome, Italy; (M.A.); (S.P.B.C.)
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, 00185 Rome, Italy; (M.A.); (S.P.B.C.)
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Davide Ferrazzi
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Michela Cazzaniga
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Luca Bonacchini
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Paolo Aseni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
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Waydhas C, Prediger B, Kamp O, Kleber C, Nohl A, Schulz-Drost S, Schreyer C, Schwab R, Struck MF, Breuing J, Trentzsch H. Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02457-3. [PMID: 38308661 DOI: 10.1007/s00068-024-02457-3] [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: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change. CONCLUSION Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.
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Affiliation(s)
- Christian Waydhas
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany.
- Department of Surgery, BG Bergmannsheil University Hospital, Bochum, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Oliver Kamp
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - Christian Kleber
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
| | - André Nohl
- Centre of Emergency Medicine, BG Duisburg Hospital, Duisburg, Germany
| | - Stefan Schulz-Drost
- Zentrum für Bewegungs- und Altersmedizin, Helios Kliniken Schwerin, Schwerin, Germany
- Department für Unfall- und Orthopädische Chirurgie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christof Schreyer
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Manuel Florian Struck
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Jessica Breuing
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Heiko Trentzsch
- Institute of Emergency Medicine and Medical Management, LMU Munich University Hospital, Munich, Germany
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Moore C, Wilson B, Oury J, Denne N, Quedado K, Fang W, Bardes JM. Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy. Am Surg 2024; 90:23-27. [PMID: 37500609 DOI: 10.1177/00031348231192061] [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: 07/29/2023]
Abstract
INTRODUCTION The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.
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Affiliation(s)
- Cody Moore
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Brandon Wilson
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Jeffrey Oury
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Nicolas Denne
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Kimberly Quedado
- Director of Research and Scholarship, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Wei Fang
- West Virginia University Clinical & Translational Science Institute, Morgantown, WV, USA
| | - James M Bardes
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
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Pokrzywa CJ, Figueroa J, Gomez J, Karam B, Murphy P, Iverson K, Morris R, Carver T, Milia D, de Moya M. Mechanical Ventilation Does Not Predict Pneumothorax Observation Failure in the Severely Injured. Am Surg 2023; 89:5246-5252. [PMID: 36448872 DOI: 10.1177/00031348221142583] [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: 12/22/2023]
Abstract
BACKGROUND Observative management of small traumatic pneumothoraces (PTX) has been shown to decrease chest tube utilization in non-mechanically ventilated patients without compromising outcomes. This approach could be used in mechanically ventilated (MV) patients, though many feel these patients are at increased risk of observation failure. METHODS A single center retrospective study of all adults undergoing observation of a computed tomography (CT) diagnosed PTX from 2015-2019. Patients with chest tube placement within 4-hours of arrival, concurrent hemothorax, or death within 24-hours were excluded. Observation failure was defined as chest tube placement. RESULTS Of 340 patients, 64 were on MV. The groups were of similar age, BMI, underlying pulmonary comorbidities, and PTX size (10.1 mm vs 8.8 mm, P = .20). The MV group was more severely injured (ISS [25+] [60.9% vs 11.2%, P < .001]). There was no difference in observation failure rates by MV status overall (6.3% vs 5.1%, P = .75) or by PTX size (<15 mm [5% vs 2.2%, P = .37], <20 mm [4.8% vs 3.1%, P = .45], <25 mm [4.8% vs 4.1%, P = .73], <30 mm [4.8% vs 4.1%, P = .73], <35 mm [4.8% vs 4.7%, P = 1.00]). MV was not an independent predictor of observation failure on multivariable analysis (OR .64, 95% CI .18-2.20), though PTX size was (OR 1.11, 95% CI 1.05-1.17). When comparing those who failed vs those who did not, the only difference was PTX size (9.34 mm vs 19.41 mm, P < .001). CONCLUSION MV is not an independent predictor of PTX observation failure. While PTX size appears to play a role, further studies are needed to outline safe parameters for observation in those undergoing MV.
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Affiliation(s)
| | - Juan Figueroa
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jose Gomez
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Basil Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Patrick Murphy
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katie Iverson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tom Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Milia
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marc de Moya
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Occult traumatic pneumothorax: Is routine follow up chest X-ray necessary? SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92:177-184. [PMID: 34538828 DOI: 10.1097/ta.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Genna Beattie
- From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California
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Smith JA, Secombe P, Aromataris E. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:1025-1040. [PMID: 34225346 DOI: 10.1097/ta.0000000000003322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this systematic review was to investigate the safety and effectiveness of conservative management versus prophylactic intercostal catheter (ICC) insertion for the management of occult pneumothoraces in mechanically ventilated patients. METHODS PubMed, Embase, CINAHL, Web of Science, Cochrane Central, and other trial registries were searched. Eligible studies were critically appraised using standardized instruments. Meta-analysis was performed with mixed-methods logistic regression where appropriate and sensitivity analyses were performed with alternative statistical methods (Stata™ 15 or RevMan 5.3) or summarized in narrative. Randomized controlled trials (RCTs) and cohort studies were analyzed separately. RESULTS Twelve studies with a total of 354 participants were included; three RCTs (178 participants) and nine cohort studies (176 participants). The majority of the included studies, particularly the cohort studies, were well conducted. Two of the RCTs were rated as low quality. Statistically significant differences were observed in the RCT analysis: ICC insertion (any reason) (odds ratio, 2.86; 95% confidence interval, 1.26-6.43, 2 RCTs) in favor of prophylactic ICC; ICC complications (odds ratio, 0.12; 95% confidence interval, 0.02-0.62, 2 RCTs) in favor of conservative management. Nonstatistically significant differences were observed for progression of pneumothorax, ICC insertion (progression to simple pneumothorax), and ICC insertion (nonpneumothorax reasons). Results of analyses showed high imprecision (wide confidence limits). Conservative management showed a low rate of tension pneumothorax (2.8%). Complications were higher in the ICC group (19.5% vs. 5.8%). CONCLUSION Available evidence suggests that conservative management is safe for the management of occult pneumothoraces in mechanically ventilated patients, especially when undergoing short-term (<4 days) ventilation. We recommend that patients undergoing mechanical ventilation for a procedure alone and patients suspected to be ventilated less than 4 days can be conservatively managed. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Affiliation(s)
- Jeremy Adam Smith
- From the JBI, Faculty of Health and Medical Sciences (J.A.S., E.A.), The University of Adelaide, SA; Intensive Care Unit (J.A.S.), The Alfred Hospital, Melbourne, VIC; Intensive Care Unit (P.S.), Alice Springs Hospital, Alice Springs, NT; School of Medicine (P.S.), Flinders University, Bedford Park, SA; and Australian and New Zealand Intensive Care Research Centre (P.S.), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Hu K, Chopra A, Kurman J, Huggins JT. Management of complex pleural disease in the critically ill patient. J Thorac Dis 2021; 13:5205-5222. [PMID: 34527360 PMCID: PMC8411157 DOI: 10.21037/jtd-2021-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 11/08/2022]
Abstract
Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.
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Affiliation(s)
- Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Jonathan Kurman
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Terrill Huggins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
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Thachuthara-George J. Pneumothorax in patients with respiratory failure in ICU. J Thorac Dis 2021; 13:5195-5204. [PMID: 34527359 PMCID: PMC8411185 DOI: 10.21037/jtd-19-3752] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022]
Abstract
Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.
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Affiliation(s)
- Joseph Thachuthara-George
- Interventional Pulmonary Program, Division of Pulmonary, Allergy, and Critical Care Medicine, UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
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Tran J, Haussner W, Shah K. Traumatic Pneumothorax: A Review of Current Diagnostic Practices And Evolving Management. J Emerg Med 2021; 61:517-528. [PMID: 34470716 DOI: 10.1016/j.jemermed.2021.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic). Traumatic PTX is a common pathology identified in the emergency department. Traditional management calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches. There is a paucity of cohesive literature on how to best manage the traumatic PTX. OBJECTIVE OF THE REVIEW This review aimed to describe current practices and future directions of traumatic PTX management. DISCUSSION Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic PTX. Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX. The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic PTX is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives. In patients with small or occult PTXs, even observation may be reasonable. CONCLUSIONS Modern management of the traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices (smaller catheters or observation). Ultimately, this shift is favorable in reducing length of stay, development of complications, and pain in the trauma patient.
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Affiliation(s)
- Jacqueline Tran
- Weill Cornell Medicine, Weill Cornell Medical College, New York, New York
| | - William Haussner
- Weill Cornell Medicine, Emergency Medicine, New-York Presbyterian Hospital, New York, New York
| | - Kaushal Shah
- Weill Cornell Medicine, Emergency Medicine, New-York Presbyterian Hospital, New York, New York
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Hershkovitz Y, Ashkenazi I, Dykman D, Shapira Z, Jeroukhimov I. Failure of observation and need for delayed tube thoracostomy in 197 unselected patients with occult pneumothorax: a retrospective study. Eur J Trauma Emerg Surg 2021; 48:1513-1518. [PMID: 33796890 DOI: 10.1007/s00068-021-01653-9] [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] [Received: 12/30/2020] [Accepted: 03/21/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Occult pneumothorax (OPTX) is defined as air in the pleural space that was not suspected on plain chest X-ray but detected on CT. Controversy exists in the management of OPTX, especially in patients who require positive pressure ventilation (PPV). In this study, we investigated the need for tube thoracostomy (TT) in blunt trauma patients with OPTX. MATERIALS AND METHODS This is a retrospective study of blunt trauma patients of all ages with evidence of OPTX, treated in the Shamir Medical Center Trauma Unit between 2008 and 2017. Two groups were defined. Group I consisted of patients requiring PPV. Group II included patients who did not require PPV. We identified the indication for TT insertion (hemothorax, significant pneumothorax, and enlarging pneumothorax). Necessity for delayed TT insertion due to enlarging pneumothorax was analyzed. RESULTS Overall 512 patients with traumatic pneumothorax were admitted. 197 (38.5%) had OPTX. Motor vehicle accidents and falls from height accounted for most of the injuries, 47.2 and 42.6%, respectively. Fifty-seven patients required PPV. TT was required in 31 (15.7%) patients. No differences were found between the overall rate of TT insertion between the groups (15.7 vs. 21.1%; p = 0.2) and for delayed insertion of a TT due to an enlarging pneumothorax (25.0 vs. 42.1%; p = 0.45). CONCLUSION TT is not indicated in every patient with OPTX even in case of mechanical ventilation.
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Affiliation(s)
- Yehuda Hershkovitz
- Trauma Unit, Shamir Medical Center, Zeriffin, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, 70300, Tel Aviv, Zerifin, Israel.
| | | | - Daniel Dykman
- Department of Surgery, Shamir Medical Center, Zeriffin, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zahar Shapira
- Department of Surgery, Shamir Medical Center, Zeriffin, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Igor Jeroukhimov
- Trauma Unit, Shamir Medical Center, Zeriffin, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, 70300, Tel Aviv, Zerifin, Israel
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OPTICC: A multicentre trial of Occult Pneumothoraces subjected to mechanical ventilation: The final report. Am J Surg 2021; 221:1252-1258. [PMID: 33641940 DOI: 10.1016/j.amjsurg.2021.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/21/2021] [Accepted: 02/05/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Patients with occult pneumothorax (OPTX) requiring positive-pressure ventilation (PPV) face uncertain risks of tension pneumothorax or chest drainage complications. METHODS Adults with traumatic OPTXs requiring PPV were randomized to drainage/observation, with the primary outcome of composite "respiratory distress" (RD)). RESULTS Seventy-five (75) patients were randomized to observation, 67 to drainage. RD occurred in 38% observed and 25% drained (p = 0.14; Power = 0.38), with no mortality differences. One-quarter of observed patients failed, reaching 40% when ventilated >5 days. Twenty-three percent randomized to drainage had complications or ineffectual drains. CONCLUSION RD was not significantly different with observation. Thus, OPTXs may be cautiously observed in stable patients undergoing short-term PPV when prompt "rescue drainage" is immediately available. As 40% of patients undergoing prolonged (≥5 days) ventilation (PPPV) require drainage, we suggest consideration of chest drainage performed with expert guidance to reduce risk of chest tube complications. LEVEL OF EVIDENCE Therapeutic study, level II.
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The management of occult hemothorax in adults with thoracic trauma: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 89:1225-1232. [DOI: 10.1097/ta.0000000000002936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031. [PMID: 32702777 PMCID: PMC7390330 DOI: 10.1002/14651858.cd013031.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes. OBJECTIVES To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy. SEARCH METHODS We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed. SELECTION CRITERIA We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non-radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta-analyses by using a bivariate model to estimate and compare summary sensitivities and specificities. MAIN RESULTS We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax. AUTHORS' CONCLUSIONS The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.
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Affiliation(s)
- Kenneth K Chan
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Daniel A Joo
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zahra A Premji
- Libraries and Cultural Resources, University of Calgary, Calgary, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Abel Wakai
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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Qamar SR, Evans D, Gibney B, Redmond CE, Nasir MU, Wong K, Nicolaou S. Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making. Can Assoc Radiol J 2020; 72:293-310. [PMID: 32268772 DOI: 10.1177/0846537120914247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.
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Affiliation(s)
- Sadia Raheez Qamar
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - David Evans
- Department of Surgery, 8167Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Gibney
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciaran E Redmond
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad Umer Nasir
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Wong
- Department of Radiology, 71511Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
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Mahmood I, Younis B, Ahmed K, Mustafa F, El-Menyar A, Alabdallat M, Parchani A, Peralta R, Nabir S, Ahmed N, Al-Thani H. Occult Pneumothorax in Patients Presenting with Blunt Chest Trauma: An Observational Analysis. Qatar Med J 2020; 2020:10. [PMID: 32206592 PMCID: PMC7075257 DOI: 10.5339/qmj.2020.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/21/2019] [Indexed: 12/02/2022] Open
Abstract
Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammad Alabdallat
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Parchani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Syed Nabir
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Nadeem Ahmed
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
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Detection of posttraumatic pneumothorax using electrical impedance tomography-An observer-blinded study in pigs with blunt chest trauma. PLoS One 2020; 15:e0227518. [PMID: 31923268 PMCID: PMC6953828 DOI: 10.1371/journal.pone.0227518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Posttraumatic pneumothorax (PTX) is often overseen in anteroposterior chest X-ray. Chest sonography and Electrical Impedance Tomography (EIT) can both be used at the bedside and may provide complementary information. We evaluated the performance of EIT for diagnosing posttraumatic PTX in a pig model. METHODS This study used images from an existing database of images acquired from 17 mechanically ventilated pigs, which had sustained standardized blunt chest trauma and had undergone repeated thoracic CT and EIT. 100 corresponding EIT/CT datasets were randomly chosen from the database and anonymized. Two independent and blinded observers analyzed the EIT data for presence and location of PTX. Analysis of the corresponding CTs by a radiologist served as reference. RESULTS 87/100 cases had at least one PTX detected by CT. Fourty-two cases showed a PTX > 20% of the sternovertebral diameter (PTXtrans20), whereas 52/100 PTX showed a PTX>3 cm in the craniocaudal diameter (PTXcc3), with 20 cases showing both a PTXtranscc and a PTXcc3. We found a very low agreement between both EIT observers considering the classification overall PTX/noPTX (κ = 0.09, p = 0.183). For PTXtrans20, sensitivity was 59% for observer 1 and 17% for observer 2, with a specificity of 48% and 50%, respectively. For PTXcc3, observer 1 showed a sensitivity of 60% with a specificity of 51% while the sensitivity of observer 2 was 17%, with a specificity of 89%. By programming a semi-automatized detection algorithm, we significantly improved the detection rate of PTXcc3, with a sensitivity of 73% and a specificity of 70%. However, detection of PTXtranscc was not improved. CONCLUSION In our analysis, visual interpretation of EIT without specific image processing or comparison with baseline data did not allow clinically useful diagnosis of posttraumatic PTX. Multimodal imaging approaches, technical improvements and image postprocessing algorithms might improve the performance of EIT for diagnosing PTX in the future.
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Factors Associated with Chest Tube Placement in Blunt Trauma Patients with an Occult Pneumothorax. Crit Care Res Pract 2019; 2019:9274697. [PMID: 31565433 PMCID: PMC6745112 DOI: 10.1155/2019/9274697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/13/2019] [Indexed: 11/18/2022] Open
Abstract
Background An occult pneumothorax is identified by computed tomography but not visualized by a plain film chest X-ray. The optimal management remains unclear. Methods A retrospective review of an urban level I trauma center's trauma registry was conducted to identify patients with occult pneumothorax over a 2-year period. Factors predictive of chest tube placement were identified using univariate and multivariate logistic regression analysis. Results A total of 131 patients were identified, of whom 100 were managed expectantly with an initial period of observation. Ultimately, 42 (32.0%) patients received chest tubes and 89 did not. The patients who received chest tubes had larger pneumothoraces at initial assessment, a higher incidence of rib fractures, and an increased average number of rib fractures, of which significantly more were displaced. Conclusions Displaced rib fractures and moderate-sized pneumothoraces are significant factors associated with chest tube placement in a victim of blunt trauma with occult pneumothorax. The optimal timing for the first follow-up chest X-ray remains unclear.
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22
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Usefulness of CT-scan in the management of chest stab trauma: a prospective observational study. Eur J Trauma Emerg Surg 2019; 46:1385-1391. [PMID: 31407022 DOI: 10.1007/s00068-019-01203-4] [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: 05/07/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI. METHODS We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients' management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). RESULTS 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. CONCLUSIONS In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.
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Patel BH, Lew CO, Dall T, Anderson CL, Rodriguez R, Langdorf MI. Chest tube output, duration, and length of stay are similar for pneumothorax and hemothorax seen only on computed tomography vs. chest radiograph. Eur J Trauma Emerg Surg 2019; 47:939-947. [DOI: 10.1007/s00068-019-01198-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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Using cable ties to connect thoracostomy tubes to drainage devices decreases frequency of unplanned disconnection. Eur J Trauma Emerg Surg 2018; 46:621-626. [PMID: 30386866 DOI: 10.1007/s00068-018-1044-2] [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: 08/14/2018] [Accepted: 10/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection. METHODS On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior ("BEFORE") and subsequent ("AFTER") to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days. RESULTS 121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same. CONCLUSIONS Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.
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Mokotedi MC, Lambert L, Simakova L, Lips M, Zakharchenko M, Rulisek J, Balik M. X-ray indices of chest drain malposition after insertion for drainage of pneumothorax in mechanically ventilated critically ill patients. J Thorac Dis 2018; 10:5695-5701. [PMID: 30505477 PMCID: PMC6236183 DOI: 10.21037/jtd.2018.09.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/06/2018] [Indexed: 10/15/2023]
Abstract
BACKGROUND Chest drain (CD) migration in the pleural cavity may result in inadequate drainage of pneumothorax. The aim of this study was to assess several parameters that might help in diagnosing CD migration on chest X-ray (CXR). METHODS Patients with a CD inserted from the safe triangle with a subsequent supine CXR and CT scan performed less than 24 hours apart were assessed for CD foreshortening, angle of inclination of the CD, and CD tortuosity. CD foreshortening was expressed as a ratio between CD length measured in coronal plane only and CD length inside the pleural cavity measured on CT. The angle of inclination of the CD was measured as the angle between the horizontal line and CD at the pleural space entry on CXR. CD tortuosity was calculated as a ratio between the distance from CD pleural space entry to the tip of the CD and the length of CD from the pleural space entry to its tip on CXR. RESULTS Altogether 28 patients were included in the study. The median time between the CXR and CT examinations was 5.4 hours (IQR, 3.8-6.9 hours). CD foreshortening was the best clue of a misplaced CD with AUC of 0.93, 100% sensitivity and 88% specificity for a cut-off value of 82%. The angle of CD inclination was greater in patients with misplaced CD with AUC of 0.83, 75% sensitivity and 92% specificity for a cut-off of 50 degrees. The performance of CD tortuosity was poor. CONCLUSIONS Greater foreshortening of the CD and a steep angle of inclination of the CD above the horizontal at chest entry should raise suspicion of CD migration and mandate further investigation by chest ultrasound to rule out residual pneumothorax occult on CXR.
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Affiliation(s)
- Masego Candy Mokotedi
- Department of Anesthesiology and Intensive Care, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Lukas Lambert
- Department of Radiology, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Lucie Simakova
- Department of Radiology, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Lips
- Department of Anesthesiology and Intensive Care, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Zakharchenko
- Department of Anesthesiology and Intensive Care, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Rulisek
- Department of Anesthesiology and Intensive Care, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1 Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Hefny AF, Kunhivalappil FT, Matev N, Avila NA, Bashir MO, Abu-Zidan FM. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore Med J 2017; 59:150-154. [PMID: 28741012 DOI: 10.11622/smedj.2017074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL.
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Affiliation(s)
- Ashraf F Hefny
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates.,Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Nikolay Matev
- Department of Radiology, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Norman A Avila
- Trauma Registry Program, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Masoud O Bashir
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
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Caspers CG. Care of Traumatic Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:673-683. [PMID: 28711130 DOI: 10.1016/j.emc.2017.03.010] [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: 10/19/2022]
Abstract
Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.
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Affiliation(s)
- Christopher G Caspers
- Ronald O. Perelman Department of Emergency Medicine, New York University Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
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28
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Sato I, Kanda H, Kanao-Kanda M, Kurosawa A, Kunisawa T. A case of iatrogenic pneumothorax in which chest tube placement could be avoided by intraoperative evaluation with transthoracic ultrasonography. Ther Clin Risk Manag 2017; 13:843-845. [PMID: 28740394 PMCID: PMC5505678 DOI: 10.2147/tcrm.s131472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report a case of iatrogenic pneumothorax in which chest tube placement was avoided by continuous intraoperative evaluation with transthoracic ultrasonography. A 53-year-old man had undergone a subsegmentectomy. While attempting to place a central venous catheter in the right internal jugular vein after the induction of anesthesia, we identified gas absorption during the puncture and suspected a pneumothorax. Chest X-ray revealed an ~5-mm collapse of the right lung apex. Tension pneumothorax was a concern during surgery because of the long-term positive pressure ventilation, but we decided to start the operation without preventative chest tube placement. During the operation, we regularly observed the midclavicular line of the second intercostal space using ultrasound. The operation was completed uneventfully. In this case, we effectively utilized ultrasound and avoided preventive chest tube placement and the associated complications. Transthoracic ultrasonography could be performed easily and continuously during surgery and was effective for evaluating the progression of an intraoperative pneumothorax.
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Affiliation(s)
- Izumi Sato
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Megumi Kanao-Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Atsushi Kurosawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takayuki Kunisawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Krogh CL, Steinmetz J, Rudolph SS, Hesselfeldt R, Lippert FK, Berlac PA, Rasmussen LS. Effect of ultrasound training of physicians working in the prehospital setting. Scand J Trauma Resusc Emerg Med 2016; 24:99. [PMID: 27491760 PMCID: PMC4973524 DOI: 10.1186/s13049-016-0289-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/26/2016] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Advances in technology have made ultrasound (US) devices smaller and portable, hence accessible for prehospital care providers. This study aims to evaluate the effect of a four-hour, hands-on US training course for physicians working in the prehospital setting. The primary outcome measure was US performance assessed by the total score in a modified version of the Objective Structured Assessment of Ultrasound Skills scale (mOSAUS). METHODS Prehospital physicians participated in a four-hour US course consisting of both hands-on training and e-learning including a pre- and a post-learning test. Prior to the hands-on training a pre-training test was applied comprising of five videos in which the participants should identify pathology and a five-minute US examination of a healthy volunteer portraying to be a shocked patient after a blunt torso trauma. Following the pre-training test, the participants received a four-hour, hands-on US training course which was concluded with a post-training test. The US examinations and screen output from the US equipment were recorded for subsequent assessment. Two blinded raters assessed the videos using the mOSAUS. RESULTS Forty participants completed the study. A significant improvement was identified in e-learning performance and US performance, (37.5 (SD: 10.0)) vs. (51.3 (SD: 5.9) p = < 0.0001), total US performance score (15.3 (IQR: 12.0-17.5) vs. 17.5 (IQR: 14.5-21.0), p = < 0.0001) and in each of the five assessment elements of the mOSAUS. CONCLUSION In the prehospital physicians assessed, we found significant improvements in the ability to perform US examinations after completing a four-hour, hands-on US training course.
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Affiliation(s)
- Charlotte Loumann Krogh
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, København Ø, Denmark. .,Emergency Medical Services Copenhagen, The Capital Region of Denmark, Telegrafvej 5, 2750, Ballerup, Denmark. .,, Sankt Thomas Allé 13, 3 th., 1824, Frederiksberg C, Denmark.
| | - Jacob Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, København Ø, Denmark.,Emergency Medical Services Copenhagen, The Capital Region of Denmark, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Søren Steemann Rudolph
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, København Ø, Denmark.,Emergency Medical Services Copenhagen, The Capital Region of Denmark, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Rasmus Hesselfeldt
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, København Ø, Denmark
| | - Freddy K Lippert
- Emergency Medical Services Copenhagen, The Capital Region of Denmark, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Peter A Berlac
- Emergency Medical Services Copenhagen, The Capital Region of Denmark, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, København Ø, Denmark
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Bensghir M, Moutaoukil M, Meziane M, Jaafari A, Hemmaoui B, Haimeur C. [Occult pneumothorax: Does it take drain before elective surgery?]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:259-263. [PMID: 27113614 DOI: 10.1016/j.pneumo.2015.12.005] [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: 02/16/2015] [Revised: 11/06/2015] [Accepted: 12/21/2015] [Indexed: 06/05/2023]
Abstract
Pneumothorax occult is defined by the presence of a non-visible to standard asymptomatic pneumothorax and pulmonary diagnosed only by X-ray computed tomography. The presence of this type of pneumothorax before planned surgery is a rare situation. What to do remains non-consensual. Through two clinic cases and a literature review, the authors discuss the modalities of management of this entity.
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Affiliation(s)
- M Bensghir
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc.
| | - M Moutaoukil
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - M Meziane
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - A Jaafari
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - B Hemmaoui
- Service d'ORL, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - C Haimeur
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
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Oh MK, Jeon WJ, Cho SY, Kwon YD, Kim KH. Development of bilateral tension pneumothorax under anesthesia in a Boerhaave's syndrome patient: a case report. Korean J Anesthesiol 2016; 69:175-80. [PMID: 27066209 PMCID: PMC4823415 DOI: 10.4097/kjae.2016.69.2.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 02/03/2015] [Accepted: 02/16/2015] [Indexed: 11/10/2022] Open
Abstract
A 33-year-old male visited the emergency room with abdominal pain which developed after a vomiting episode. Based on the pneumomediastinum findings from a chest radiograph and a contrast-enhanced chest and abdominal computed tomography scan, the patient was diagnosed with Boerhaave's syndrome. Preoperative radiologic findings showed no pneumothorax or pleural effusion. Once anesthesia was administered, the patient developed near complete cardiopulmonary collapse due to a bilateral tension pneumothorax, which was treated by bilateral thoracentesis, followed by chest tube insertion. Despite a left side rupture, the damaged right lung was unable to overcome single right ventilation, so the surgery was completed via right thoracotomy. The ruptured site was treated, and the patient was transferred to the intensive care unit. We discuss the anesthetic implications of this disease and how to prevent fatal complications.
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Affiliation(s)
- Mi Kyung Oh
- Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Woo Jae Jeon
- Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sang Yun Cho
- Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Yong Deok Kwon
- Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Kyoung Hun Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Guri, Korea
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Anesthetic Considerations and Ventilation Strategies in Cardiothoracic Trauma. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zhang M, Teo LT, Goh MH, Leow J, Go KTS. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy? Eur J Trauma Emerg Surg 2016; 42:785-790. [PMID: 26860113 DOI: 10.1007/s00068-016-0645-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/01/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION/BACKGROUND Occult pneumothorax (OPTX) is defined as air within the pleural cavity that is undetectable on normal chest X-rays, but identifiable on computed tomography. Currently, consensus is divided between tube thoracostomy and conservative management for OPTX. METHODS The aim of this retrospective study is to determine whether OPTX can be managed conservatively and whether any adverse events occur under conservative management. Data on all trauma patients from 1 Jan 2010 to 31 December 2012 were obtained from our hospital's trauma registry. All patients with occult pneumothorax who had chest X-ray (CXR) and any CT scan visualizing the thorax were included. The exclusion criteria included those with penetrating wounds; CXR showing pneumothorax, hemothorax, or hemopneumothorax; those with prophylactic chest tube insertion before CT; and those with no CT diagnosis of OPTX. The complications of these patients were analyzed to determine if tube thoracostomy is necessary for OPTX and whether not inserting it would alter the outcome significantly. RESULTS A total of 1564 cases were reviewed and 83 patients were included. Of these 83 patients, 35 (42.2 %) had tube thoracostomy after OPTX detection and 48 (57.8 %) were observed initially. Patients who had tube thoracostomy had similar ISS compared to those without (median ISS 17 vs. 18.5, p = 0.436). Out of the 48 patients who did not have tube thoracostomy on detection of an OPTX, 4 (8.3 %) had complications. In the group of 35 patients who had tube thoracostomy on detection of an OPTX, 7 (20 %) had complications. Of the 83 patients, a total of 12 patients had IPPV, of which 7 (58.3 %) had tube thoracostomy and 5 (41.7 %) did not. Patients who had tube thoracostomy under our care have a statistically significant likelihood of experiencing any complication compared to those without tube thoracostomy (odds ratio 9.92. The median length of stay was also longer (13 days) in those who had tube thoracostomy compared to those without (5 days) (p value = 0.008). CONCLUSIONS Our study suggests that patients with OPTX can be managed conservatively with close monitoring, but only in areas with ready access to emergency facilities should any adverse events occur.
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Affiliation(s)
- M Zhang
- Department of Orthopaedics, National University Hospital, Singapore, Singapore.
| | - L T Teo
- Trauma and Acute Care Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - M H Goh
- Trauma and Acute Care Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore
| | - K T S Go
- Trauma and Acute Care Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Affiliation(s)
- Paul B McBeth
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA
| | - Stephanie A Savage
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA.
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Fulton C, Bratu I. Occult pneumothoraces in ventilated pediatric trauma patients: a review. Can J Surg 2015; 58:177-80. [PMID: 25799129 DOI: 10.1503/cjs.009314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Currently there is no clinical consensus on how to treat occult pneumothoraces in adults, and even less research has been done in children. We sought to understand the outcomes of severely injured, ventilated children with occult pneumothoraces. METHODS Using the Alberta Trauma Registry, we retrospectively reviewed the charts of all ventilated pediatric patients at a children's hospital from 2001 to 2011 who had an injury severity score greater than 12 and a diagnosis of occult pneumothorax (seen on computed tomography scan but not on supine chest radiograph). RESULTS There were 1689 severely injured children, with 496 admitted to the pediatric intensive care unit (PICU) and ventilated. A total of 130 children were found to have pneumothoraces, and of those, 96 were admitted to the PICU. Of those, 15 children had a total of 19 occult pneumothoraces, and all were successfully treated without chest tubes. The average age was 13.4 (range 2.0-17.0) years, and 54% of these children were male. The average time spent on the ventilator was 2.3 (range 0-13) days, and 7 children had at least 1 operation. CONCLUSION In our institution, occult pneumothoraces occur in very few severely injured, ventilated pediatric trauma patients. Our study adds to the increasing evidence in the adult and pediatric literature suggesting that occult pneumothoraces may be safely observed even while under positive-pressure ventilation.
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Affiliation(s)
- Courtney Fulton
- The Division of Pediatric General Surgery, Department of Surgery, University of Alberta, Edmonton, Alta
| | - Ioana Bratu
- The Division of Pediatric General Surgery, Department of Surgery, University of Alberta, Edmonton, Alta
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Charbit J, Millet I, Maury C, Conte B, Roustan JP, Taourel P, Capdevila X. Prevalence of large and occult pneumothoraces in patients with severe blunt trauma upon hospital admission: experience of 526 cases in a French level 1 trauma center. Am J Emerg Med 2015; 33:796-801. [PMID: 25881742 DOI: 10.1016/j.ajem.2015.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Occult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation. METHODS Patients with severe trauma consecutively admitted to our institution for 5 years were retrospectively analyzed. All patients with blunt thoracic trauma who had undergone computed tomographic (CT) within the first hour of hospitalization were included. Mechanical ventilation was considered as early if it was introduced in the prehospital period or on arrival at the hospital. Occult PTXs were defined as PTXs not visible on chest x-ray. All PTXs were measured on CT scan (largest thickness and vertical dimension). Large occult PTXs were defined by a largest thickness of 30 mm or more. RESULTS Of the 526 patients studied, 395 (75%) were male, mean age was 37.9 years, mean Injury Severity Score was 22.2, and 247 (47%) received early mechanical ventilation. Of 429 diagnosed PTXs, 296 (69%) were occult. The proportion of occult PTXs classified as large was 11% (95% confidence interval, 8%-15%). The overall prevalence of large occult PTXs was 6% (95% confidence interval, 4%-8%). Both CT measurements and proportion of large occult PTXs were found statistically comparable in patients with or without mechanical ventilation. CONCLUSIONS Six percent of studied patients with severe trauma had a large and occult PTX as soon as admission despite a normal chest x-ray result. The observed sizes and rates of occult PTX were comparable regardless of the initiation of early mechanical ventilation.
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Affiliation(s)
- Jonathan Charbit
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France; Montpellier I University, Montpellier, France.
| | - Ingrid Millet
- Montpellier I University, Montpellier, France; Department of Radiology, Lapeyronie University Hospital, Montpellier, France
| | - Camille Maury
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Benjamin Conte
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Jean-Paul Roustan
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Patrice Taourel
- Montpellier I University, Montpellier, France; Department of Radiology, Lapeyronie University Hospital, Montpellier, France
| | - Xavier Capdevila
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France; Montpellier I University, Montpellier, France; Institut National de la Santé et de la Recherche Médicale, Equipe soutenue par la Région et l'Inserm U1046 (X.C.), Montpellier, France
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Llaquet Bayo H, Montmany Vioque S, Rebasa P, Navarro Soto S. [Results of conservative treatment in patients with occult pneumothorax]. Cir Esp 2015; 94:232-6. [PMID: 25804518 DOI: 10.1016/j.ciresp.2015.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/10/2015] [Accepted: 01/25/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION An occult pneumothorax is found in 2-15% trauma patients. Observation (without tube thoracostomy) in these patients presents still some controversies in the clinical practice. The objective of the study is to evaluate the efficacy and the adverse effects when observation is performed. METHODS A retrospective observational study was undertaken in our center (university hospital level II). Data was obtained from a database with prospective registration. A total of 1087 trauma patients admitted in the intensive care unit from 2006 to 2013 were included. RESULTS In this period, 126 patients with occult pneumothorax were identified, 73 patients (58%) underwent immediate tube thoracostomy and 53 patients (42%) were observed. Nine patients (12%) failed observation and required tube thoracostomy for pneumothorax progression or hemothorax. No patient developed a tension pneumothorax or experienced another adverse event related to the absence of tube thoracostomy. Of the observed patients 16 were under positive pressure ventilation, in this group 3 patients (19%) failed observation. There were no differences in mortality, hospital length of stay or intensive care length of stay between the observed and non-observed group. CONCLUSION Observation is a safe treatment in occult pneumothorax, even in pressure positive ventilated patients.
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Affiliation(s)
- Heura Llaquet Bayo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Institut Universitari Parc Taulí-Universitat Autònoma de Barcelona, Barcelona, España.
| | - Sandra Montmany Vioque
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Institut Universitari Parc Taulí-Universitat Autònoma de Barcelona, Barcelona, España
| | - Pere Rebasa
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Institut Universitari Parc Taulí-Universitat Autònoma de Barcelona, Barcelona, España
| | - Salvador Navarro Soto
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Institut Universitari Parc Taulí-Universitat Autònoma de Barcelona, Barcelona, España
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de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, Bonnet PM, D'Journo XB. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg 2014; 20:399-408. [PMID: 25476459 DOI: 10.1093/icvts/ivu397] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
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Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Lucile Gust
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Claudia Natale
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre-Mathieu Bonnet
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Xavier-Benoît D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
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McCullough AL, Haycock JC, Forward DP, Moran CG. Early management of the severely injured major trauma patient. Br J Anaesth 2014; 113:234-41. [PMID: 25038155 DOI: 10.1093/bja/aeu235] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The major trauma team relies on an efficient, communicative team to ensure patients receive the best quality care. This requires a comprehensive handover, rapid systematic review, and early management of life- and limb-threatening injuries. These multiple injured patients often present with complex conditions in a dynamic situation. The importance of team work, communication, senior decision-making, and documentation cannot be underestimated.
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Affiliation(s)
| | - J C Haycock
- Nottingham University Hospital, Nottingham, UK
| | - D P Forward
- Nottingham University Hospital, Nottingham, UK
| | - C G Moran
- Nottingham University Hospital, Nottingham, UK
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Volpicelli G, Boero E, Sverzellati N, Cardinale L, Busso M, Boccuzzi F, Tullio M, Lamorte A, Stefanone V, Ferrari G, Veltri A, Frascisco MF. Semi-quantification of pneumothorax volume by lung ultrasound. Intensive Care Med 2014; 40:1460-7. [PMID: 25056671 DOI: 10.1007/s00134-014-3402-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lung ultrasound (LUS) may accurately diagnose pneumothorax. However, there is uncertainty about its usefulness in the quantification of pneumothorax size. To determine the ability of LUS in the semi-quantification of pneumothorax volume, we compared the projection of the lung point (LP) with the pneumothorax volume measured by computerized tomography (CT) and the interpleural distance on chest radiography (CXR). METHODS We performed LUS in patients with pneumothorax and all the LP located on the chest wall were compared to CXR and CT studies. The primary outcome of the study was the ability of LP to grade pneumothorax volumes measured by CT. The secondary outcome was the accuracy of LP to predict small and large pneumothorax according to the societal guidelines based on CXR reading. RESULTS A total of 124 patients with pneumothorax were enrolled (76 spontaneous, 20 traumatic and 28 post-procedural). Ninety-four CXR and 58 CT were available for the analysis. An LP posterior to the mid axillary line corresponded to three different CXR criteria for large pneumothorax with sensitivity from 81.4 to 88.2 % and specificity from 64.7 to 72.6 %. The mid axillary line also represented the limit for predicting greater than 15 % of lung collapse when volume is measured at CT, with sensitivity 83.3 % and specificity 82.4 %. CONCLUSIONS LUS-targeted assessment of LP was a useful predictor of pneumothorax volume in this research study setting. LUS reliably classified pneumothorax size when compared to criteria based on CXR reading, particularly the small sized pneumothorax. However, LUS greatly outperformed conventional CXR reading for a graded quantification of the percentage of lung collapse.
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Affiliation(s)
- Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy,
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Rankin D, Mathew PS, Kurnutala LN, Soghomonyan S, Bergese SD. Tension Pneumothorax During Surgery for Thoracic Spine Stabilization in Prone Position: A Case Report and Review of Literature. J Investig Med High Impact Case Rep 2014; 2:2324709614537233. [PMID: 26425610 PMCID: PMC4528895 DOI: 10.1177/2324709614537233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The intraoperative progression of a simple or occult pneumothorax into a tension pneumothorax can be a devastating clinical scenario. Routine use of prophylactic thoracostomy prior to anesthesia and initiation of controlled ventilation in patients with simple or occult pneumothorax remains controversial. We report the case of a 75-year-old trauma patient with an insignificant pneumothorax on the right who developed an intraoperative tension pneumothorax on the left side while undergoing thoracic spine stabilization surgery in the prone position. Management of an intraoperative tension pneumothorax requires prompt recognition and treatment; however, the prone position presents an additional challenge of readily accessing the standard anatomic sites for pleural puncture and air drainage.
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Affiliation(s)
- Demicha Rankin
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul S Mathew
- Ohio State University Wexner Medical Center, Columbus, OH, USA
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Roberts DJ, Niven DJ, James MT, Ball CG, Kirkpatrick AW. Thoracic ultrasonography versus chest radiography for detection of pneumothoraces: challenges in deriving and interpreting summary diagnostic accuracy estimates. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:416. [PMID: 24976173 PMCID: PMC4056348 DOI: 10.1186/cc13759] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Volpicelli G, Boero E, Stefanone V, Storti E. Unusual new signs of pneumothorax at lung ultrasound. Crit Ultrasound J 2013; 5:10. [PMID: 24355346 PMCID: PMC3923561 DOI: 10.1186/2036-7902-5-10] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 12/10/2013] [Indexed: 01/08/2023] Open
Abstract
Background The diagnosis of pneumothorax with a bedside lung ultrasound is a powerful methodology. The conventional lung ultrasound examination consists of a step-by-step procedure targeted towards the detection of four classic ultrasound signs, the lung sliding, the B lines, the lung point and the lung pulse. In most cases, a combination of these signs allows a safe diagnosis of pneumothorax. However, the widespread application of sonographic methodology in clinical practice has brought out unusual cases which raise new sonographic signs. The purpose of this article was to introduce some of these new signs that are described after the analysis of unusual and complex cases encountered during the clinical daily practice in an emergency department. Findings The double lung point consists of the alternating patterns of sliding and non-sliding lung intermittently appearing at the two opposite sides of the scan. The septate pneumothorax allows B lines and lung pulse to be still visible in a condition of pneumothorax with absent sliding. In hydropneumothorax, the air/fluid border is imaged by lung ultrasound as the interposition between an anechoic space and a non-sliding A-pattern, a sign that may be named hydro-point. Conclusions In bedside lung ultrasound, the operator should be aware and interpret double lung point, septate pneumothorax and hydro-point. The conventional diagnostic protocol of bedside lung ultrasound for pneumothorax should be occasionally adapted to such complex cases.
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Affiliation(s)
- Giovanni Volpicelli
- Emergency Medicine, San Luigi Gonzaga University Hospital, Turin 10043, Italy.
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