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Hernandez OK, Sushereba C, Militello L, San Miguel C, Wolf S, Allen TT, Patterson ES. Strategies for case-based training with virtual patients: An experimental study of the impact of integrating mental model articulation and self-reflection. APPLIED ERGONOMICS 2024; 118:104265. [PMID: 38479217 DOI: 10.1016/j.apergo.2024.104265] [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: 08/23/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 05/03/2024]
Abstract
Resilient system performance in high-stakes settings, which includes the ability to monitor, respond, anticipate, and learn, can be enhanced for trainees through simulation of realistic scenarios enhanced by augmented reality. Active learning strategies can enhance simulation-based training, particularly the mental model articulation principle where students are prompted to anticipate what will happen next and the reflection principle where students self-assess their performance compared to a gold standard expert model. In this paper, we compared simulation-based training for trauma care with and without active learning strategies during pauses in the simulated action for progressively deteriorating patients. The training was conducted online and real-time without a facilitator, with 42 medical students viewing training materials and then immediately taking an online quiz for three types of trauma cases: hemorrhage, airway obstruction, and tension pneumothorax. Participants were randomly assigned to either the experimental or control condition in a between-subjects design. We compared performance in the control and experimental conditions based on: A) the proportion of cues correctly recognized, B) the proportion of accurate diagnoses, C) the proportion of appropriate treatment interventions, and D) verbal briefing quality on a 1-5 scale. We found that the training intervention increased recognition of subtle cues critical for accurate diagnosis and appropriate treatment interventions; the training did not improve the accuracy of diagnoses or the quality of the verbal briefing. We conclude that incorporating active learning strategies in simulation-based training improved foundational capabilities in detecting subtle cues and intervening to rescue deteriorating patients that can increase the readiness for trainees to contribute to resilient system performance in the high-stakes setting of emergency care in hospitals.
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Affiliation(s)
- Olivia K Hernandez
- Ohio State University, School of Health and Rehabilitation Sciences, Columbus, OH, USA
| | | | | | | | | | - Theodore T Allen
- Ohio State University, Department of Integrated Systems Engineering, Columbus, OH, USA
| | - Emily S Patterson
- Ohio State University, School of Health and Rehabilitation Sciences, Columbus, OH, USA.
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2
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Naumann DN, Sellon E, Mitchinson S, Tucker H, Marsden MER, Norris-Cervetto E, Bafitis V, Smith T, Bradley R, Alzarrad A, Naeem S, Smith G, Dillane S, Humphrys-Eveleigh A, Wordsworth M, Sanchez-Thompson N, Bootland D, Brown L. Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study. BMJ Mil Health 2024; 170:123-129. [PMID: 35584853 DOI: 10.1136/bmjmilitary-2022-002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging. METHODS A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score. RESULTS There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups. CONCLUSION Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.
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Affiliation(s)
- David N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - E Sellon
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Mitchinson
- Emergency Department, Barts Health NHS Trust, London, UK
| | - H Tucker
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | - M E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, Barts Health NHS Trust, London, UK
| | - E Norris-Cervetto
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Bafitis
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T Smith
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Bradley
- Emergency Department, Barts Health NHS Trust, London, UK
| | - A Alzarrad
- Emergency Department, Barts Health NHS Trust, London, UK
| | - S Naeem
- Emergency Department, Barts Health NHS Trust, London, UK
| | - G Smith
- Emergency Department, Barts Health NHS Trust, London, UK
| | - S Dillane
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | | | - M Wordsworth
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - N Sanchez-Thompson
- Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - D Bootland
- Emergency Department, Brighton and Sussex University Hospitals NHS Trust, Worthing, UK
| | - L Brown
- Emergency Department, Brighton and Sussex University Hospitals NHS Trust, Worthing, UK
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3
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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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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Trauma Emerg Surg 2023; 49:2031-2046. [PMID: 37430174 PMCID: PMC10520188 DOI: 10.1007/s00068-023-02271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany.
| | - Janusz Andres
- Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Luca Brazzi
- The Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Edoardo De Robertis
- The Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Sharon Einav
- The Intensive Care Unit, Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Carl Gwinnutt
- The Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bahar Kuvaki
- The Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey
| | - Pawel Krawczyk
- The Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew D McEvoy
- The Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pieter Mertens
- The Department of Anaesthesiology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Vivek K Moitra
- Division of Critical Care Anesthesiology, The Department of Anesthesiology, Columbia University, Columbia, NY, USA
| | - Jose Navarro-Martinez
- The Anesthesiology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), Biomedical Research (ISABIAL), Alicante, Spain
| | - Mark E Nunnally
- The Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael O Connor
- The Department of Anesthesiology & Critical Care, University of Chicago, Chicago, IL, USA
| | - Marcus Rall
- The Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany
| | - Kurt Ruetzler
- The Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jan Schmitz
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Karl Thies
- The Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Bethel, Germany
| | - Jonathan Tilsed
- The Department of Surgery, Hull University Teaching Hospitals, Hull, UK
| | - Mauro Zago
- General & Emergency Surgery Division, The Department of Surgery, A. Manzoni Hospital, Milan, Italy
| | - Arash Afshari
- The Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
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5
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O'Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Anaesthesiol 2023; 40:724-736. [PMID: 37218626 DOI: 10.1097/eja.0000000000001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- From the University Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, University Hospital Ruhr-University Bochum, Minden, Germany (JH), Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital of Cologne, Cologne, Germany (BWB, JS), Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland (JA), Department of Surgical Sciences, University of Turin, Turin (LB), Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Italy (EdR), Intensive Care Unit, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE), Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK (CG), Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey (BK), Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland (PK), Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium (PM), Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee (MDM), Division of Critical Care Anesthesiology, Department of Anesthesiology, Columbia University, New York, USA (VKM), Anesthesiology Department, Dr Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), and Biomedical Research (ISABIAL), Alicante, Spain (JN-M), Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York (MEN), Department of Anesthesiology & Critical Care, University of Chicago, Illinois, USA (MO'C), Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany (MR), Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (KR), Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Germany (KT), Department of Surgery, Hull University Teaching Hospitals, Hull, UK (JT), General & Emergency Surgery Division, Department of Surgery, A. Manzoni Hospital, Milan, Italy (MZ) and Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet, Denmark and Department of Clinical Medicine, University of Copenhagen, Denmark (AA)
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6
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [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: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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7
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Okoye OG, Olaomi OO, Adamu YB, Anumenechi N. Thoracic trauma in national hospital Abuja, Nigeria: The epidemiology, injury severity and initial management options. Afr J Emerg Med 2023; 13:15-19. [PMID: 36700166 PMCID: PMC9852269 DOI: 10.1016/j.afjem.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/16/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023] Open
Abstract
Background Trauma is the leading cause of death in individuals between the ages of 1 and 44 years and it is the third commonest cause of death regardless of age. Thoracic trauma is a relatively common cause of preventable death among trauma patients. The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. This study is intended to discuss the epidemiology, severity and initial management strategies in chest trauma patients, in a low income country. Methods A cross sectional retrospective study among chest trauma patients seen in the emergency room of National Hospital Trauma Centre, Abuja, Nigeria, from January 2015 to December 2017. Relevant patients' information was retrieved from the trauma registry kept in the trauma centre. Data processing and analysis was done using statistical package for social sciences (SPSS) version 24. Test of significance was done where applicable using chi square and student t test, using p value less than 0.05 as significant. Results are presented in tables and figures. Results A total of 637 patients, male to female ratio of 3.6 and mean age of 34.18 ± 11.34 were enrolled into the study. The most common mechanisms of injury were MVC (54.6%) and assault (23.5%). Blunt injuries were 3.5 times more frequent than the penetrating injuries. The RTS of 12 (76.3%) and the ISS of 1-15 category (52.3%) were the most common scores. Up to 98% of patients were managed non-operatively. Recovery rate was high (89%) with relatively low mortality rate of 4.2%. Conclusion Majority of thoracic trauma can be managed effectively by employing simple, non-operative procedures such as needle decompression and chest tube insertion. Efforts should be made to include these procedures in the skill set of every medical officer working in the emergency room, particularly in low and middle income countries where there is paucity of emergency physicians.
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Affiliation(s)
- Onyedika Godfrey Okoye
- Trauma Centre, Department of Surgery, National Hospital Abuja, Central Business District, Garki, Abuja, Nigeria
- Corresponding author.
| | - Oluwole Olayemi Olaomi
- Trauma Centre, Department of Surgery, National Hospital Abuja, Central Business District, Garki, Abuja, Nigeria
| | - Yahaya Baba Adamu
- Cardiothoracic Division, Department of Surgery, National Hospital Abuja, Nigeria
| | - Ndubisi Anumenechi
- Cardiothoracic Division, Department of Surgery, National Hospital Abuja, Nigeria
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8
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Shock in Trauma. Emerg Med Clin North Am 2023; 41:1-17. [DOI: 10.1016/j.emc.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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9
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Lou Y, Zhang Y, Wang Z, Zhao C, Li Z, Huang Q, Tang H, Xiao J. Large pneumothorax following thoracic and lumbar tumor surgery: Risk factors and management strategies. Front Surg 2023; 10:1066841. [PMID: 36778648 PMCID: PMC9909098 DOI: 10.3389/fsurg.2023.1066841] [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] [Received: 10/11/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Objective Large pneumothorax is a rare but dangerous complication following thoracic and lumbar tumor surgery. There is little discussion about the features of large pneumothorax following spinal tumor surgery. The purpose of this study was to analyze the characteristics of postoperative pneumothorax, identify factors related to large pneumothorax, and propose a management algorithm for prevention, diagnosis, and treatment. Methods Included in this retrospective study were 118 patients who developed pneumothorax after receiving thoracic and lumbar tumor surgery between January 2015 and October 2021. A measurement of lung compression ≥20% on chest CT or x-ray was defined as large pneumothorax, and potential risk factors for large pneumothorax were identified by univariate analysis. Results Spinal tumor history and intraoperative blood loss were risk factors for large pneumothorax. The common symptoms of postoperative pneumothorax were chest pain, chest tightness and dyspnea. The mean longest transverse diameter of tumors was 6.63 ± 2.4 cm. En bloc resection was performed in 70 patients, with a mean operation time of 6.9 ± 2.5 h and mean intraoperative blood loss of 1771 ± 1387 ml. The most common pathologies were chondrosarcoma, giant cell tumors of bone, and neurogenic tumors. Conclusion During surgery, an artificial dura mater patch and a prolene suture can be used to repair the pleural and lung defects. We recommend chest CT as the preferred method for identifying postoperative pneumothorax. If a patient presents severe dyspnea, a large pneumothorax or concurrent pleural effusion, application of chest drainage is strongly recommended.
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Affiliation(s)
- Yan Lou
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Military Medical University, ShanghaiChina
| | - Yunyan Zhang
- Department of Respiratory and Critical Care Medicine, Changzheng Hospital, Naval Military Medical University, Shanghai China
| | - Zhongzhao Wang
- Department of Respiratory and Critical Care Medicine, Changzheng Hospital, Naval Military Medical University, Shanghai China
| | - Chenglong Zhao
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Military Medical University, ShanghaiChina
| | - Zhenxi Li
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Military Medical University, ShanghaiChina
| | - Quan Huang
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Military Medical University, ShanghaiChina,Correspondence: Quan Huang Hao Tang Jianru Xiao
| | - Hao Tang
- Department of Respiratory and Critical Care Medicine, Changzheng Hospital, Naval Military Medical University, Shanghai China,Correspondence: Quan Huang Hao Tang Jianru Xiao
| | - Jianru Xiao
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Military Medical University, ShanghaiChina,Correspondence: Quan Huang Hao Tang Jianru Xiao
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10
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Iyengar KP, Venkatesan AS, Jain VK, Shashidhara MK, Elbana H, Botchu R. Risks in the Management of Polytrauma Patients: Clinical Insights. Orthop Res Rev 2023; 15:27-38. [PMID: 36974036 PMCID: PMC10039633 DOI: 10.2147/orr.s340532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.
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Affiliation(s)
- Karthikeyan P Iyengar
- Department of Orthopaedics, Southport and Ormskirk NHS Trust, Southport, UK
- Correspondence: Karthikeyan P Iyengar, Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, UK, PR8 6PN, Tel +44-1704-704926, Email
| | | | - Vijay K Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Husam Elbana
- Department of Orthopaedics, Royal Lancaster Infirmary, Lancaster, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
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11
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Hafeez A, Nadeem N, Iqbal J, Qureshi A, Shakeel A, Zafar U. Concordance Between Resident and Attending Radiologist in Reporting Pneumothorax on Intensive Care Unit and Emergency Room Chest Radiographs. Cureus 2022; 14:e29672. [PMID: 36320981 PMCID: PMC9616555 DOI: 10.7759/cureus.29672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs. Materials and methods This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the “Comments” section of the picture archiving and communication system (PACS). Further entries were made in the department’s “Panic Logbook.” Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement. Results Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph. The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out. Conclusion In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008).
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Okano DR, Chen AW, Mitchell SA, Cartwright JF, Moore C, Boyer TJ. Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents. Healthcare (Basel) 2022; 10:healthcare10091787. [PMID: 36141399 PMCID: PMC9498657 DOI: 10.3390/healthcare10091787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Anesthesiologists may encounter multiple obstacles in communication when attempting to collect information for emergency surgeries. Occult tension pneumothorax that was asymptomatic in the emergency department (ED) could become apparent upon positive pressure ventilation and pose a critical threat to the patient intraoperatively. Here, we describe a simulation exercise that was developed as a curriculum module for the Indiana University (IU) Anesthesiology residency program. It is primarily designed for first-year clinical anesthesia residents (CA-1/PGY-2). It is a 50 min encounter with two scenarios. The first scenario focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scenario focuses on the early diagnosis of tension pneumothorax and subsequent treatment. The residents were given formative feedback and met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, and anaphylaxis. Residents rated the feedback and debriefing as “extremely useful” or “very useful.” Time constraints limit the number of residents who can sit in the “hot seat.” The structure of the mannequin limits the ability to diagnose pneumothorax by auscultation and ultrasound. In the future, the scenarios may also be utilized to educate student anesthesiologist assistants and other non-physician anesthesia learners.
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Affiliation(s)
- David Ryusuke Okano
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Correspondence:
| | - Andy W. Chen
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sally A. Mitchell
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Johnny F. Cartwright
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Christopher Moore
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Tanna J. Boyer
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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13
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Kang S, Kim Y, Kim DH. A rare complication: Tension pneumothorax after peroral endoscopic myotomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seokin Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yuri Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Ata F, Yousaf Z, Farsakoury R, Khan AA, Arshad A, Omran M, Ananthegowda DC, Khatib M, Chughtai TS. Spontaneous tension pneumothorax as a complication of Coronavirus disease 2019: Case report and literature review. Clin Case Rep 2022; 10:e05852. [PMID: 35582160 PMCID: PMC9083808 DOI: 10.1002/ccr3.5852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Primary spontaneous tension pneumothorax (STP) is a rare and life‐threatening condition. We report a case of COVID‐19‐pneumonia patient who developed STP as a complication. He had a prolonged hospital stay and was ultimately discharged asymptomatic. A systematic literature search was performed to review studies (N=12) reporting STP in the setting of COVID‐19.
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Affiliation(s)
- Fateen Ata
- Department of Internal Medicine Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | - Rana Farsakoury
- Department of Plastic Surgery Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | - Adeel Ahmad Khan
- Department of Endocrinology Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | - Abdullah Arshad
- Department of Internal Medicine Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | - Maya Omran
- Medical Intensive Care Unit Hazm Mebaireek Hospital Hamad Medical Corporation Doha Qatar
| | | | - Mohamad Khatib
- Medical Intensive Care Unit Hazm Mebaireek Hospital Hamad Medical Corporation Doha Qatar
| | - Talat Saeed Chughtai
- Trauma Surgery and Thoracic Surgery Hamad General Hospital Hamad Medical Corporation Doha Qatar
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15
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Fuzzy-entropic approach on chest X-ray region of interest segmentation-heart position shifting using differential evolution optimization and multi-level segmentation technique with cloud computing. Soft comput 2022. [DOI: 10.1007/s00500-022-07006-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Tirimanna R, Myerson J, Okorie M, Dorman E. Diagnosis of spontaneous secondary tension pneumothorax following apparent recovery from coronavirus disease 2019 pneumonitis: a case report. J Med Case Rep 2022; 16:88. [PMID: 35193689 PMCID: PMC8861998 DOI: 10.1186/s13256-022-03313-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 has been associated with a plethora of different manifestations of systems affected (including pulmonary, gastrointestinal, and thrombotic disease) and time to presentation of complications. Pneumothorax has been established as a complication in the literature. However, tension pneumothorax remains a rare presentation with higher mortality. We report a case of secondary tension pneumothorax in a patient following apparent recovery from coronavirus disease 2019 pneumonitis. CASE PRESENTATION Eight days after resolution of coronavirus disease 2019 pneumonitis symptoms, a 51-year-old Caucasian man with no pre-existing pulmonary disease was brought into the emergency department following 48 hours of progressive shortness of breath. Further clinical assessment revealed reduced breath sounds in the right lung, blood pressure was 116/95 mmHg, and jugular venous pressure was not elevated. Chest x-ray showed right-sided tension pneumothorax with mediastinal shift. Insertion of a chest drain led to rapid resolution of symptoms, and the patient was discharged following full re-expansion of the lung. CONCLUSIONS The period of recovery from coronavirus disease 2019 is variable. Clinicians should consider tension pneumothorax as a possible complication of coronavirus disease 2019 pneumonitis in patients presenting with type 1 respiratory failure, even after resolution of pneumonitis symptoms and a considerable time period following initial contraction of coronavirus disease 2019.
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Affiliation(s)
- Romesh Tirimanna
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
| | - James Myerson
- Respiratory Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Michael Okorie
- Clinical Pharmacology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Eleanor Dorman
- Barking Havering and Redbridge Hospitals NHS Trust, London, UK
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17
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To Watch Before or Listen While Doing? A Randomized Pilot of Video-Modelling versus Telementored Tube Thoracostomy. Prehosp Disaster Med 2022; 37:71-77. [PMID: 35177133 DOI: 10.1017/s1049023x22000097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted. METHODS Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure. RESULTS There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000). CONCLUSIONS Random evaluation revealed both paradigms have attributes. If VM can be utilized during "travel-time," it is quicker but without facilitating "trouble shooting." On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.
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18
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Bird R, Braunold D, Matava CT. Chest trauma in children-what an anesthesiologist should know. Paediatr Anaesth 2022; 32:340-345. [PMID: 34811835 DOI: 10.1111/pan.14340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022]
Abstract
Injury is the leading cause of death in children, with chest trauma accounting for 25% of this mortality. In addition, these patients often present with multiple system injuries, which require simultaneous management. These concurrent injuries can lead to challenges when prioritizing tasks in the resuscitation room and during anesthetic management. In addition, changes from spontaneous ventilation to positive pressure ventilation can impact lung physiology. Therefore, a clear communication plan with careful monitoring and vigilance is needed for intubation and ventilation in these children. These injuries also require specific strategies to prevent barotrauma which could lead to complications such as respiratory failure, pneumonia, sepsis, and acute respiratory distress syndrome. This educational review aims to guide clinicians managing pediatric chest trauma through some of the critical decision-making regarding intubation, ventilation, and subsequent management of injuries.
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Affiliation(s)
- Ruth Bird
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Braunold
- Department of Anesthesia, Rambam Medical Center, Haifa, Israel
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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19
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Mohrsen S, McMahon N, Corfield A, McKee S. Complications associated with pre-hospital open thoracostomies: a rapid review. Scand J Trauma Resusc Emerg Med 2021; 29:166. [PMID: 34863280 PMCID: PMC8643006 DOI: 10.1186/s13049-021-00976-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/04/2021] [Indexed: 02/26/2023] Open
Abstract
Background Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. Main findings A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. Conclusion There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00976-1.
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Affiliation(s)
- Stian Mohrsen
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK. .,Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
| | - Niall McMahon
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Alasdair Corfield
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Sinéad McKee
- Department of Nursing, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
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20
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Griffiths E. Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2021; 29:163. [PMID: 34801070 PMCID: PMC8606084 DOI: 10.1186/s13049-021-00977-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/04/2021] [Indexed: 02/01/2023] Open
Abstract
Background Auscultating for breath sounds to assess for pneumothorax in the helicopter emergency medical services (HEMS) settings can be extremely challenging. Thoracic point of care ultrasound (POCUS) offers a seemingly more useful visual (rather than audible) alternative. This review critically and quantitatively evaluates the use of thoracic POCUS for pneumothorax in the HEMS setting. Methods A systematic literature review with meta-analysis was conducted. Only papers reporting on patients undergoing POCUS for pneumothorax in the helicopter or pre-hospital setting were included. Primary outcome was accuracy, focusing on sensitivity and specificity. Secondary outcome was practicality. PubMed, Embase and the Cochrane Library were searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess validity of studies. Results Twelve studies reporting on n = 1,936 images from medical and trauma patients were included in qualitative synthesis. Studies were nearly all observational designs. Most images were acquired by nurses or paramedics who were previously novices to ultrasound. The reference standard was predominantly CT. Specificity results were unanimously precise and very high, whereas sensitivity results were imprecise and extremely variable. Meta-analysis of eight studies involving n = 1,713 images yielded pooled sensitivity 61% (95% CI: 27–87%; I2 = 94%) and pooled specificity 99% (95% CI: 98–100%; I2 = 89%). Six studies involving n = 315 images reported practicality. The highest or second highest categorisation of image quality was reported in around half of those images. Conclusion Thoracic POCUS is highly specific but has extremely variable sensitivity for pneumothorax when performed in the HEMS setting. This is from purely a diagnostic (not clinical) perspective. Sensitivity increases when only clinically significant pneumothoraces are considered. Case reports reveal thoracic POCUS can appropriately alter treatment and triage decisions, but only for a small number of patients. It appears predominantly useful in mitigating against unnecessary interventions. More research reporting patient focused outcomes is required. In the meantime, thoracic POCUS appears to offer a more appropriate visual alternative to auscultation for breath sounds when assessing for pneumothorax in the HEMS setting.
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Affiliation(s)
- Edward Griffiths
- Bristow Helicopters Search and Rescue, UK Search and Rescue Helicopter Service, Aberdeen, UK. .,Queen Mary University London, London, UK.
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21
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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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22
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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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23
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Geraci TC, Williams D, Chen S, Grossi E, Chang S, Cerfolio RJ, Bizekis C, Zervos M. Incidence, Management, and Outcomes of Patients With COVID-19 and Pneumothorax. Ann Thorac Surg 2021; 114:401-407. [PMID: 34481799 PMCID: PMC8413091 DOI: 10.1016/j.athoracsur.2021.07.097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 12/02/2022]
Abstract
Background Our objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). Methods A single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. Results From March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). Conclusions The incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.
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Affiliation(s)
- Travis C Geraci
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.
| | - David Williams
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Stacey Chen
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Eugene Grossi
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Stephanie Chang
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Costas Bizekis
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Michael Zervos
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
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25
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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: 3] [Impact Index Per Article: 1.0] [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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Petta BFV, Cazanti RF, Fontes CER. An experimental pleural drainage device in hypertensive pneumothorax. Acta Cir Bras 2021; 36:e360708. [PMID: 34431922 PMCID: PMC8405241 DOI: 10.1590/acb360708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/25/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To develop a specific device for pleural drainage in hypertensive
pneumothorax. Methods The prototype was modeled from the free version of a 3D modeling application,
printed on a 3D printer using ABS® plastic material, and tested
in a pleural drainage simulator. Results Pleural drainage in the simulator using the prototype was feasible and
reproducible. Conclusions While the prototype is functional in the simulator, it requires improvement
and refinement for use in humans.
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27
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Lewis BT, Herr KD, Hamlin SA, Henry T, Little BP, Naeger DM, Hanna TN. Imaging Manifestations of Chest Trauma. Radiographics 2021; 41:1321-1334. [PMID: 34270354 DOI: 10.1148/rg.2021210042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ©RSNA, 2021.
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Affiliation(s)
- Brittany T Lewis
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - Keith D Herr
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - Scott A Hamlin
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - Travis Henry
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - Brent P Little
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - David M Naeger
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
| | - Tarek N Hanna
- From the Department of Radiology and Imaging Sciences, Emory University, 550 Peachtree Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H., T.N.H.); Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, Calif (T.H.); Department of Radiology, Harvard Medical School, Boston, Mass (B.P.L.); Department of Radiology, Denver Health and Hospital Authority, Denver, Colo (D.M.N.); and Department of Radiology, University of Colorado, Denver, Colo (D.M.N.)
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Somma J, Marques E, Bussières JS. In reply: Non-ventilated lung airway occlusion during one-lung ventilation: a need for further research? Can J Anaesth 2021; 68:1458-1459. [PMID: 34155612 DOI: 10.1007/s12630-021-02054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jacques Somma
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada
| | | | - Jean S Bussières
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada.
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Abstract
INTRODUCTION Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting. METHODS A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system. RESULTS A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart. CONCLUSIONS Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.
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Newton G, Laing CM, Reay G, King-Shier K. Thoracic Endotracheal Tube Insertion During Prehospital Thoracostomy: A Case Report. Air Med J 2021; 40:182-184. [PMID: 33933223 DOI: 10.1016/j.amj.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
This case highlights the novel use of endotracheal tubes to maintain patency of simple thoracostomies (STs) performed to relieve a tension pneumothorax after failed needle thoracostomy (NT). Treatment of a tension pneumothorax in the prehospital setting is typically performed using NT because of the minimal equipment required and rapid application. However, the variable efficacy of NT has led to a rise in the use of ST as an alternative procedure to treat a tension pneumothorax. A potential complication of ST is the occlusion of the thoracostomy site, which, left unresolved, may lead to the reoccurrence of tension physiology. In a resource-rich setting, such as in a hospital, the ST would be followed by tube thoracostomy to ensure patency. Unfortunately, this may not be feasible in prehospital environments where constraints exist because of time, equipment, and personnel. A review of the literature surrounding prehospital ST reveals previous reports of endotracheal tubes being used to maintain patency temporarily. However, no cases documenting the successful use of this novel procedure in an air medical setting were found at the time of writing. This case documents the successful use of this novel procedure during the treatment of a polytraumatized adult female resulting from a motorcycle crash.
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Affiliation(s)
- Graham Newton
- Shock Trauma Air Rescue Service, Calgary, Alberta, Canada.
| | | | - Gudrun Reay
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
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31
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Horrocks R. Boerhaave syndrome, a rare oesophageal rupture: a case report. Br Paramed J 2021; 5:49-53. [PMID: 34421375 PMCID: PMC8341059 DOI: 10.29045/14784726.2021.3.5.4.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Boerhaave syndrome is a disorder mainly unknown among ambulance staff. However, the high mortality and morbidity rates associated with this rare disorder, and the fact that other conditions present with similar symptoms, suggest that this is one disorder to add to the differential diagnosis list. This case study describes a 17-year-old male complaining of left-sided ‘pressure’-type chest pain and persistent vomiting who on examination was found to have subcutaneous emphysema present. Deceived by a differential diagnosis, the patient was transferred under the belief that he had suffered a spontaneous pneumothorax as he was tall, young and thin. This case report reviews the literature surrounding Boerhaave syndrome and how it can present.
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32
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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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33
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Plötzlicher Brustschmerz und Unterleibsschmerzen. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Nolan B, Hillier M. Unlearning the ABCs: a call to reprioritize prehospital intubation for trauma patients. CAN J EMERG MED 2021; 23:271-273. [PMID: 33959924 DOI: 10.1007/s43678-020-00050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Brodie Nolan
- Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, USA. .,Li Ka Shing Knowledge Institute, Toronto, ON, USA. .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, USA.
| | - Morgan Hillier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, USA.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, USA.,Sunnybrook Centre for Prehospital Medicine, Toronto, ON, USA
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35
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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Abstract
Cardiac arrest in the operating room and in the immediate postoperative period is a potentially catastrophic event that is almost always witnessed and is frequently anticipated. Perioperative crises and perioperative cardiac arrest, although often catastrophic, are frequently managed in a timely and directed manner because practitioners have a deep knowledge of the patient's medical condition and details of recent procedures. It is hoped that the approaches described here, along with approaches for the rapid identification and management of specific high-stakes clinical scenarios, will help anesthesiologists continue to improve patient outcomes.
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Affiliation(s)
- Benjamin T Houseman
- Memorial Healthcare System Anesthesiology Residency Program, Envision Physician Services, 703 North Flamingo Road, Pembroke Pines, FL 33028, USA
| | - Joshua A Bloomstone
- Envision Physician Services, 7700 W Sunrise Boulevard, Plantation, FL 33322, USA; University of Arizona College of Medicine-Phoenix, 475 N 5th Street, Phoenix, AZ 85004, USA; Division of Surgery and Interventional Sciences, University of College London, Centre for Perioperative Medicine, Charles Bell House, 43-45 Foley Street, London, WIW 7TS, England
| | - Gerald Maccioli
- Quick'r Care, 990 Biscayne Boulevard #501, Miami, FL 33132, USA.
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37
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Rovner MS, Jeanes ZM, Redding AT, Davis GP, Furse CM. Delayed hypoxia during pediatric posterior spinal fusion secondary to intraoperative pneumothorax: Case report. Clin Case Rep 2020; 8:2273-2275. [PMID: 33235775 PMCID: PMC7669371 DOI: 10.1002/ccr3.3095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 11/06/2022] Open
Abstract
Rarely will a pneumothorax caused intraoperatively not manifest signs such as hypoxia, tachypnea, and tachycardia until later. If this occurs, diagnosis and treatment with needle decompression or chest tube must happen quickly for patient safety.
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Affiliation(s)
- Michelle S. Rovner
- Department of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Zachary M. Jeanes
- Department of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Amanda T. Redding
- Department of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Grayce P. Davis
- Department of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Cory M. Furse
- Department of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharlestonSCUSA
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38
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Ronaldson J, Moultrie CEJ, Corfield AR, McElhinney E. Can non-physician advanced retrieval practitioners (ARP) acquire and interpret diagnostic views of the lungs with sufficient quality to aid in the diagnosis of pneumothorax in the pre-hospital and retrieval environment? Scand J Trauma Resusc Emerg Med 2020; 28:102. [PMID: 33066800 PMCID: PMC7565770 DOI: 10.1186/s13049-020-00797-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 10/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background As an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. However, the published evidence supporting non-physicians use of ultrasound in this setting is limited. Aim We aimed to establish if Advanced Retrieval Practitioners (non-physicians) could acquire ultrasound views of the lungs and interpret them with sufficient quality to diagnose pneumothorax in the pre-hospital and retrieval environment when compared to expert review. Method The study consisted of an observational trial from April 2017 to April 2018. Twelve (12) patients bilateral lung ultrasound images (24 images) were randomly selected from 87 patients assessed using Point of Care Ultrasound (POCUS) by three Advanced Retrieval Practitioners in the Pre-hospital and Retrieval environment. Two expert reviewers’ evaluated these images to determine ARPs ability to acquire diagnostic quality images and interpret them correctly. CXR results of patients in whom lung ultrasound was undertaken were recorded as the reference standard investigation. Results Within the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review. Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images). One pneumothorax was detected on CXR in a patient with inadequate ultrasound images. Advanced Retrieval Practitioners were therefore able to both obtain adequate images and correctly diagnose pneumothorax in the pre-hospital environment with 66.6% sensitivity (95%CI 66.6–100%) and 100% specificity (95%CI 81.0–100%) compared to expert review. Conclusion Advanced Retrieval Practitioners (non-physicians) can obtain diagnostic views of the lungs of sufficient quality to diagnose the presence, or particularly the absence, of pneumothorax in the pre-hospital and retrieval environment. Although Advanced Retrieval Practitioners were less accurate than the expert reviewers at interpreting the quality of the ultrasound images, the result was not statistically significant, despite the ARPs possibly having been at a methodological disadvantage.
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Affiliation(s)
| | - Christopher E J Moultrie
- ScotSTAR, 180 Abbotsinch Road, Glasgow, PA2 3RY, USA.,Emergency Department, University Hospital Wishaw, Wishaw, UK
| | - Alasdair R Corfield
- ScotSTAR, 180 Abbotsinch Road, Glasgow, PA2 3RY, USA.,Emergency Department, Royal Alexandra Hopsital, Paisley, UK
| | - Evelyn McElhinney
- Department of Nursing & Community Health, Glasgow Caledonian University, Glasgow, UK
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Gemal H, Lu TC, Peeceeyen S. Delayed massive haemopneumothorax with shock after 'Zumba'. ANZ J Surg 2020; 91:E212-E213. [PMID: 32845555 DOI: 10.1111/ans.16283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/26/2020] [Accepted: 08/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Hugo Gemal
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia.,Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - Thomas Chengxuan Lu
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia.,Emergency Department, St George Hospital, Sydney, New South Wales, Australia.,The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Sheen Peeceeyen
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia
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40
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Castle-Kirszbaum M, Wang YY, King J, Uren B, Kim M, Danks RA, Goldschlager T. Tension Pneumocephalus from Positive Pressure Ventilation Following Endoscopic Skull Base Surgery: Case Series and an Institutional Protocol for the Management of Postoperative Respiratory Distress. World Neurosurg 2020; 141:357-362. [PMID: 32562901 DOI: 10.1016/j.wneu.2020.06.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression. CASE DESCRIPTION Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches. CONCLUSIONS To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.
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Affiliation(s)
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Health, Melbourne, Australia
| | - James King
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Brent Uren
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Martin Kim
- Department of Anaesthesia, Monash Health, Monash University, Melbourne, Australia
| | - R Andrew Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
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Abstract
Background Pneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma. Objectives This study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction. Methods In a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis. Results Among the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction. Conclusions Possible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area. Level of Evidence: 4 ![]()
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[Current treatment concepts for trauma-related cardiac arrest : Focal points, differences and similarities]. Anaesthesist 2020; 68:132-142. [PMID: 30778605 DOI: 10.1007/s00101-019-0538-6] [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: 10/27/2022]
Abstract
Trauma-related deaths are not only a relevant medical problem but also a socioeconomic one. The care of a polytraumatized patient is one of the less commonly occurring missions in the rescue and emergency medical services. The aim of this article is to compare the similarities and differences between different course concepts and guidelines in the treatment of trauma-related cardiac arrests (TCA) and to filter out the main focus of each concept. Because of the various approaches in the treatment of polytraumatized patients, there are decisive differences between trauma-related cardiac arrests and cardiac arrests from other causes.
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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Lee SK, Seo KH, Kim YJ, Youn EJ, Lee JS, Park J, Moon HS. Cardiac arrest caused by contralateral tension pneumothorax during one-lung ventilation: - A case report. Anesth Pain Med (Seoul) 2020; 15:78-82. [PMID: 33329794 PMCID: PMC7713858 DOI: 10.17085/apm.2020.15.1.78] [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: 05/15/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Tension pneumothorax on the contralateral lung during one-lung ventilation (OLV) can be life-threatening if not rapidly diagnosed and managed. However, diagnosis is often delayed because the classic signs of tension pneumothorax are similar to clinical manifestations commonly observed during OLV. Case We report a case of contralateral tension pneumothorax in a patient undergoing right upper lobectomy during OLV. The patient suffered from sudden cardiac arrest and was assisted by extra-corporeal membrane oxygenation. Conclusions Contralateral pneumothorax during OLV is rare but can occur at any time. Therefore, anesthesiologists should consider this critical complication.
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Affiliation(s)
- Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - You Jung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Eun Ji Youn
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jun Suck Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jieun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyun Soo Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
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Reichelt A, Meinel FG, Wirth S, Weber MA, Bath K. [Sudden chest pain and lower abdominal pain : The usual suspects]. Radiologe 2019; 60:216-225. [PMID: 31820015 DOI: 10.1007/s00117-019-00618-9] [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: 11/29/2022]
Abstract
CLINICAL PROBLEM Sudden chest pain and sudden abdominal pain are among the most common reasons that lead patients to the emergency room. The heterogeneous field of possible, sometimes serious diagnoses requires a structured and rapid interdisciplinary clarification in order to be able to promptly provide patients with an adequate therapy. STANDARD RADIOLOGICAL PROCEDURES Knowing the "usual suspects" of sudden chest and abdominal pain enables the radiologist to quickly select the appropriate imaging method that allows a diagnosis to be made without delay. In addition to pain localization and character, age, gender, any previous illnesses and laboratory results are taken into account in the differential diagnosis. METHODICAL INNOVATION AND EVALUATION The technical state of computer tomography (CT) now ensures that most diagnoses can be clarified due to its excellent spatial and temporal resolution. In the abdomen, however, ultrasound should continue to be used at least for primary evaluation. Only if there is a further need for abdominal imaging afterwards is CT indicated for clarification. Magnetic resonance imaging is rarely used in the emergency setting of abdominal pain except to avoid radiation exposure in children or pregnant women. RECOMMENDATION FOR THE PRACTICE Knowledge of the usual diagnoses that cause sudden chest or abdominal pain, as well as knowledge of the appropriate examination procedures and classic radiological signs are essential to avoid errors and delays in the emergency diagnosis of sudden chest and abdominal pain.
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Affiliation(s)
- Angela Reichelt
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Felix G Meinel
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Stefan Wirth
- Institut für Radiologie, Schnittbilddiagnostik, DONAUISAR Klinikum Deggendorf, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover, Perlasberger Str. 41, 94469, Deggendorf, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Kristina Bath
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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Yang W, Zhou Y, Qiu J, Tao C, Wu W, Lin N, Yang C, Zhang J, Zhang H, Wang Y. An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a canine model. Asian J Surg 2019; 43:826-831. [PMID: 31806213 DOI: 10.1016/j.asjsur.2019.10.013] [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: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND/OBJECTIVE Thoracic injuries commonly occur after blunt or penetrating trauma, leading to a blowing wound. For thoracic damage control in emergency, we evaluated a novel chest wound treatment device manufactured using expandable material with a one-way valve, and compared it with closed thoracic drainage for first-line treatment of traumatic pneumothorax in a canine model. METHODS Twenty beagle dogs (10 males and 10 females) were randomly and equally divided into two groups. After arteriovenous catheterization, an open pneumothorax model was established in the beagle dog using a minimally invasive procedure. The experimental group was treated using our test device, while the control group was treated by closed thoracic drainage. Animal survival, oxygen saturation (SO2), oxygen pressure (PO2), and changes in chest radiograph with reference to open pneumothorax before and after intervention were recorded at 30, 60, and 120 min. RESULTS After a 24-h experimental period, all animals survived. The control group recovered more quickly than the experimental group at 30 min post-trauma. However, the indices were close to normal 120 min after the test device was inserted. During the puncture, chest-wall hemorrhage was stopped by using the device, whereas the control group experienced continual errhysis. The lung had almost re-expanded at the end of the experiment in both groups. The effect of pulmonary re-expansion in the control group was better than that in the experimental group at 120 min. CONCLUSION The novel expandable one-way valve device is a safe and useful tool for the treatment of open chest trauma in emergency based on our animal experiment.
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Affiliation(s)
- Weijin Yang
- Department of General Surgery, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Youxu Zhou
- Department of General Surgery, The Third Affiliated Hospital of Fujian Traditional Chinese Medical University, Fuzhou, Fujian, China
| | - Jianshen Qiu
- Interventional Ward, Department of Medical Imaging, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Chaochao Tao
- Department of Radiology, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Weihang Wu
- Department of General Surgery, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Nan Lin
- Department of General Surgery, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Chao Yang
- Interventional Ward, Department of Medical Imaging, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Ji Zhang
- Interventional Ward, Department of Medical Imaging, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
| | - Hongwen Zhang
- Interventional Ward, Department of Medical Imaging, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China.
| | - Yu Wang
- Department of General Surgery, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China.
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Mandt MJ, Hayes K, Severyn F, Adelgais K. Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography. PREHOSP EMERG CARE 2019; 23:663-671. [PMID: 30624127 DOI: 10.1080/10903127.2019.1566422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. Methods: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. Results: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). Conclusion: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT.
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Sakuraba S, Omae T, Kawagoe I, Koh K, Inada E. Respiratory failure caused by impending tension pneumothorax after extrapleural pneumonectomy: a case report. JA Clin Rep 2018; 4:45. [PMID: 32026087 PMCID: PMC6967187 DOI: 10.1186/s40981-018-0184-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background Case presentation Conclusions
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50
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Hwang TS, Yoon YM, Jung DI, Yeon SC, Lee HC. Usefulness of transthoracic lung ultrasound for the diagnosis of mild pneumothorax. J Vet Sci 2018; 19:660-666. [PMID: 30041286 PMCID: PMC6167337 DOI: 10.4142/jvs.2018.19.5.660] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/29/2018] [Accepted: 07/02/2018] [Indexed: 01/23/2023] Open
Abstract
The aim of the present study was to investigate the diagnostic accuracy of ultrasonography in the detection of mild pneumothorax using computed tomography (CT) in dogs. Nine adult healthy beagles were included in the study. A thoracic tube was inserted into pleural space at the left thoracic wall, and each dog underwent the examinations in the order of CT, lung ultrasonography, and radiography before the infusion of room air into the pleural space. Two, 3, and 5 mL/kg infusions of room air were sequentially introduced into the pleural space and CT, lung ultrasound, and radiography examinations were performed. Sonographic signs included A-lines, stratosphere, lung sliding, lung point, lung pulse, and reverse sliding signs. Radiographs were evaluated for the absence or presence of a pneumothorax. Lung ultrasound results were more accurate than radiography results for the detection of mild pneumothorax. The overall sensitivity of the sonographic reverse sliding sign was higher than that of other sonographic signs, and its specificity was 100% for detection of mild pneumothorax. Thus, the reverse sliding sign is useful when using lung ultrasonography for diagnosis of mild pneumothorax.
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Affiliation(s)
- Tae Sung Hwang
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea
| | - Young Min Yoon
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea
| | - Dong In Jung
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea
| | - Seong Chan Yeon
- College of Veterinary Medicine, Seoul National University, Seoul 08826, Korea
| | - Hee Chun Lee
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea
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