The Diagnosis and Treatment of Non-Cardiac Thoracic Trauma

Impact of obesity on outcomes after surgical stabilization of multiple rib fractures: Evidence from the US nationwide inpatient sample

BACKGROUND

Obesity is a global health issue with increasing prevalence. Surgical procedures, such as surgical stabilization of rib fractures (SSRF), may be affected by obesity-related complications. The objective of the study is to investigate the effects of obesity on SSRF outcomes in multiple rib fractures.

METHODS

This retrospective study analyzed data from adults aged ≥ 20 years in the Nationwide Inpatient Sample (NIS) database diagnosed with multiple rib fractures who underwent SSRF between 2005 and 2018. It investigated the relationship between obesity and in-patient outcomes, such as discharge status, length of stay (LOS), in-hospital mortality, hospital costs, and adverse events using logistic and linear regression analyses.

RESULTS

Analysis of data from 1,754 patients (morbidly obese: 87; obese: 106; normal weight: 1,561) revealed that morbid obesity was associated with longer LOS (aBeta = 0.07, 95% CI: 0.06, 0.07), higher hospital costs (aBeta = 47.35, 95% CI: 38.55, 56.14), increased risks of adverse events (aOR = 1.63, 95% CI: 1.02, 2.61), hemorrhage/need for transfusion (aOR = 1.77, 95% CI: 1.12, 2.79) and mechanical ventilation ≥ 96 hours (aOR = 2.14, 95% CI: 1.28, 3.58) compared to normal weight patients. Among patients with flail chest, morbid obesity was significantly associated with tracheostomy (aOR = 2.13, 95% CI: 1.05, 4.32), ARDS/respiratory failure (aOR = 2.01, 95% CI: 1.09, 3.70), and mechanical ventilation ≥ 96 hours (aOR = 2.80, 95% CI: 1.47, 5.32). In contrast, morbid obesity had no significant associations with these adverse respiratory outcomes among patients without a flail chest (p > 0.05).

CONCLUSIONS

Morbid obesity is associated with adverse outcomes following SSRF for multiple rib fractures, especially for flail chest patients.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on motor vehicle crashes: Logistic regression approach

OBJECTIVE

Chest injuries that occur in motor vehicle crashes (MVCs) include rib fractures, pneumothorax, hemothorax, and hemothorax depending on the injury mechanism. Many risk factors are associated with serious chest injuries from MVCs. The Korean In-Depth Accident Study database was analyzed to identify risk factors associated with motor vehicle occupants' serious chest injury.

METHODS

Among 3,697 patients who visited the emergency room in regional emergency medical centers after MVCs between 2011 and 2018, we analyzed data from 1,226 patients with chest injuries. Vehicle damage was assessed using the Collision Deformation Classification (CDC) code and images of the damaged vehicle, and trauma scores were used to determine injury severity. Serious chest injury was defined as an Abbreviated Injury Scale (AIS) score for the chest code was more than 3. The patients were divided into two groups: serious chest injury patients with MAIS ≥ 3 and those with non-serious chest injury with MAIS < 3. A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on MVCs was constructed by a logistic regression analysis.

RESULTS

Among the 1,226 patients with chest injuries, 484 (39.5%) had serious chest injuries. Patients in the serious group were older than those in the non-serious group (p=.001). In analyses based on vehicle type, the proportion of light truck occupants was higher in the serious group than in the non-serious group (p=.026). The rate of seatbelt use was lower in the serious group than in the non-serious group (p=.008). The median crush extent (seventh column of the CDC code) was higher in the serious group than in the non-serious group (p<.001). Emergency room data showed that the rates of intensive care unit (ICU) admission and death were higher among patients with serious injuries (p<.001). Similarly, the general ward/ICU admission data showed that the transfer and death rates were higher in patients with serious injuries (p<.001). The median ISS was higher in the serious group than in the non-serious group (p<.001). A predictive model was derived based on sex, age, vehicle type, seating row, belt status, collision type, and crush extent. This predictive model had an explanatory power of 67.2% for serious chest injuries. The model was estimated for external validation using the confusion matrix by applying the predictive model to the 2019 and 2020 data of the same structure as the data at the time of model development in the KIDAS database.

CONCLUSIONS

Although this study had a major limitation in that the explanatory power of the predictive model was weak due to the small number of samples and many exclusion conditions, it was meaningful in that it suggested a model that could predict serious chest injuries in motor vehicle occupants (MVOs) based on actual accident investigation data in Korea. Future studies should yield more meaningful results, for example, if the chest compression depth value is derived through the reconstruction of MVCs using accurate collision speed values, and better models can be developed to predict the relationship between these values and the occurrence of serious chest injury.

Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries.

METHODS

This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days.

RESULTS

A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)].

CONCLUSIONS

In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries.

STUDY TYPE

Systematic Review and meta-analysis.

A rare case of migration of ballistic projectile from left to right main bronchus

A foreign body in the bronchus due to a ballistic projectile is very uncommon. A 45-year-old man presented to the hospital after being accidentally shot. The initial radiographic assessment found a bullet in his left thoracic cavity. With the help of an X-ray, an urgent left posterolateral thoracotomy was conducted, but no foreign body was found. The foreign body had migrated to the contralateral chest cavity, as determined by the C-arm. On the following day, a thorax computed tomography scan was conducted, and it was discovered that the foreign body had already migrated to the right lower bronchus. A right thoracotomy was then performed to remove the foreign body. He was moved to the intensive care unit and discharged with a stable condition. In conclusion, migration of a foreign body in the bronchus is rare. A thorough strategy is required to prevent the object from migrating even further.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes

PURPOSE

Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes.

METHOD

We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing.

RESULTS

Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities.

CONCLUSION

Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Risk Factors Associated with Mortality in Severe Chest Trauma Patients Admitted to the ICU

Our objective was to determine outcomes of severe chest trauma admitted to the ICU and the risk factors associated with mortality. An observational, prospective, and multicenter registry of trauma patients admitted to the participating ICUs (March 2015-December 2019) was utilized to collect the patient data that were analyzed. Severe chest trauma was defined as an Abbreviated Injury Scale (AIS) value of ≥3 in the thoracic area. Logistic regression analysis was used to evaluate the contribution of severe chest trauma to crude and adjusted ORs for mortality and to analyze the risk factors associated with mortality. Overall, 3821 patients (39%) presented severe chest trauma. The sample's characteristics were as follows: a mean age of 49.88 (19.21) years, male (77.6%), blunt trauma (93.9%), a mean ISS of 19.9 (11.6). Crude and adjusted (for age and ISS) ORs for mortality in severe chest trauma were 0.78 (0.68-0.89) and 0.43 (0.37-0.50) (p < 0.001), respectively. In-hospital mortality in the severe chest trauma patients without significant traumatic brain injury (TBI) was 5.63% and was 25.71% with associated significant TBI (p < 0.001). Age, the severity of injury (NISS and AIS-head), hemodynamic instability, prehospital intubation, acute kidney injury, and multiorgan failure were risk factors associated with mortality. The contribution of severe chest injury to the mortality of trauma patients admitted to the ICU was very low. Risk factors associated with mortality were identified.

Clinical Features, Management, and Outcomes of Chest Trauma at a Tertiary-Care Centre in India: A Retrospective Observational Study

Introduction

Chest is one of the main sites of injuries in trauma being a part of the torso. Many important organs lie in rib cage. However, data on chest injuries are scarce.

Methods

A retrospective study was carried out for chest trauma patients including polytrauma (n = 184) from hospital records for five years (2016–2020). Various parameters including demographic profile, mode of injury, management, and outcomes were studied.

Results

Mean age of patients was 37 ± 16 years with a male to female ratio of 2.4 : 1. Road traffic injuries remained the most common cause of trauma followed by assaults. Most of the patients were managed conservatively (55.43%). Mortality was seen in only 1.63% patients.

Conclusion

Young male patients are usually affected by trauma. Road traffic injuries are the commonest cause. However, most patients can be managed by conservative treatment and mortality is seen only in polytrauma patients in the present study.

The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis

BACKGROUND

Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures.

METHODS

This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes.

RESULTS

Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05).

CONCLUSIONS

Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.

The Association of Body Mass Index and Outcomes in Adult Patients with Chest Wall Injuries

BACKGROUND

Thoracic injury secondary to rib fractures following motor vehicle collisions (MVCs) significantly contribute to morbidity and mortality. While obesity has reached epidemic proportions, little is known regarding how BMI impacts outcomes in MVCs. The aim of this study was to examine how BMI impacts outcomes in MVC patients with rib fractures.

METHODS

The ACS-TQIP Database was utilized to evaluate adult MVC patients with ≥3 rib fractures. Patients with a non-thoracic AIS ≥3 were excluded, to focus on chest injuries. Patients were sorted according to the presence or absence of flail chest injuries and BMI into groups with a low (<15), intermediate (15-24), or severe (≥25) ISS.

RESULTS

Overweight and obese patients in the non-flail cohort had decreased odds of pneumothorax in all ISS groups (P < 0.05). Overweight (P = 0.049) and obese (P = 0.011) patients in the low ISS non-flail cohort had decreased odds of splenic laceration. In the non-flail cohort, obese patients with a low and intermediate ISS had decreased odds of pulmonary contusion (P < 0.01). Obese patients in the low and intermediate ISS non-flail cohorts had increased odds of PE (P < 0.05). In both the flail and non-flail cohorts, obese patients with an intermediate ISS had decreased odds of liver laceration (P < 0.05), as well as a longer HLOS, ICU-LOS, and mechanical ventilation time (P < 0.01).

CONCLUSION

Obesity affects associated injuries, complications, and hospital outcomes in a complex way after MVC related chest wall trauma. Thus, the effect of BMI should be taken into consideration when assessing and treating obese MVC trauma patients.

Yoga-An Alternative Form of Therapy in Patients with Blunt Chest Trauma: A Randomized Controlled Trial

BACKGROUND

Yoga as alternative form of therapy has shown positive impact on pulmonary functions, exercise capacity, behavioral changes, and inflammation in non-trauma patients. However, the efficacy of Yoga has not been studied in chest trauma patients.

METHODS

This randomized controlled trial was conducted at level-1 Trauma Centre. Isolated chest injury patients were randomized into either standard physiotherapy or Yogatherapy groups. Patients in physiotherapy group received conventional chest physiotherapy and Yogatherapy group received a set of Yogic exercises in addition to conventional chest physiotherapy. Primary outcome measure was changes in pulmonary function tests (PFT) at 4 weeks of discharge. Secondary outcomes were changes in quality of life (QoL), respiratory muscle strength and endurance, chest wall mobility, and levels of cytokines at 4 weeks. Data were analyzed using STATA v14.0.

RESULTS

A total of 89 eligible patients were randomized to physiotherapy (n = 46) and Yoga therapy (n = 43) groups. Demographic characteristics were comparable in both the groups. There were statistically significant improvements in PFT in the Yogatherapy group compared with physiotherapy with an increase in Forced vital capacity (p = 0.02) and Forced expiratory volume (p = 0.01) at 4 weeks. In addition, there were significant improvement in physical component of QoL, respiratory muscle endurance (p = 0.003) and axillary cirtometry (p = 0.009) in the Yogatherapy group. However, no statistically significant difference in the trends of cytokine markers seen between the groups.

CONCLUSION

Yoga was found to be effective in improving pulmonary functions and QoL in patients with chest trauma. (Trial registered at ctri.nic.in/clinicaltrials/login.php, numberREF/2016/05/011,287).

Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study

Abstract

Objectives

Thoracic trauma (TT) is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Its management is still a very challenging task. The purpose of this study was to analyse the risk factors affecting the outcome in a high-volume trauma centre and the efficacy of a specialised trauma team in level 1 trauma centres.

Patients and methods

Between January 2003 and December 2012, data of all patients admitted to the accident and emergency (A&E) department were prospectively collected at the German Trauma Registry (GTR) and thereafter retrospectively analysed.

Patients with chest trauma, an Injury Severity Score (ISS) ≥ 18 and an Abbreviated Injury Scale (AIS) > 2 in more than one body region were included. Patients were divided into two groups: group I included patients presenting with thoracic trauma between January 2003 and December 2007. The results of this group were compared with the results of another group (group II) in a later 5-year period (Jan. 2008–Dec. 2012). Univariate and multivariate analyses were performed, and differences with p < 0.05 were considered statistically significant.

Results

There were 630 patients (56%) with thoracic trauma. A total of 540 patients (48%) had associated extrathoracic injuries. Group I consisted of 285 patients (197 male, mean age 46 years). Group II consisted of 345 patients (251 male, mean age 49 years). Overall 90-day mortality was 17% (n = 48) in group I vs. 9% (n = 31) in group II (p = 0.024). Complication rates were higher in group I (p = 0.019). Higher Injury Severity Scores (ISSs) and higher Abbreviated Injury Acale (AIS) scores in the thoracic region yielded a higher rate of mortality (p < 0.0001). Young patients (< 40 years) were frequently exposed to severe thoracic injury but showed lower mortality rates (p = 0.014). Patients with severe lung contusions (n = 94) (15%) had higher morbidity and mortality (p < 0.001). Twenty-three (8%) patients underwent emergency thoracotomy in group I vs. 14 patients (4%) in group II (p = 0.041). Organ replacement procedures were needed in 18% of patients in group I vs. 31% of patients in group II (p = 0.038).

Conclusions

The presence of severe lung contusion, a higher ISS and AIS_thoracic score and advanced age are independent risk factors that are directly related to a higher mortality rate. Management of blunt chest trauma with corrective chest tube insertion, optimal pain control and chest physiotherapy results in good outcomes in the majority of patients. Optimal management with better survival rates is achievable in specialised centres with multidisciplinary teamwork and the presence of thoracic surgical experience.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

Thoracic damage control surgery

Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24-48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.

Management of blunt pulmonary injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

A penetrating dorsal thoracic injury that is lucky from every aspect: A case report

INTRODUCTION

Penetrating thoracic trauma management represents a major problem for emergency department staff. In these cases, we reported a patient, who can be deemed very lucky, because of both the trauma mechanism and the provided first aid at scene.

PRESENTATION OF CASE

A 30-year-old man was transported to the emergency surgery outpatient clinic after being stabbed from his back. A knife entered thorax from the dorsal region paravertebrally between two scapulae. No vascular and thoracic injuries were detected in the CT. The knife was then pulled and removed, and pressure dressing was applied on the wound. He was discharged with full recovery on the second day of admission.

DISCUSSION

Thoracic traumas may present as blunt or penetrating traumas. Trauma with penetrating dorsal thoracic injuries is usually in the form of stabbing, sharp penetrating object injuries, or firearm injuries. The aim of a successful trauma management is to determine whether a life-threatening condition exists. The general rules of penetrating trauma management are to avoid in-depth exploration for wound site assessment, to avoid removal of penetrating object without accurate diagnosis, and to keep in mind the possibility of intubation for airway security in every moment.

CONCLUSION

During the initial care of patients with penetrating trauma, the object should not be removed from its place. Our patient was lucky enough in that no thoracic pathology developed during the accident and he was not subjected to any secondary trauma during ambulance transport.

Clinical Presentation and Time-Based Mortality in Patients With Chest Injuries Associated With Road Traffic Accidents

Background:

Blunt chest trauma (BCT) poses significant morbidity and mortality worldwide.

Objectives:

We investigated the clinical presentation and outcome of BCT related to road traffic accidents (RTA).

Patients and Methods:

A retrospective observational analysis for patients who sustained BCT secondary to RTA in terms of motor vehicle crash (MVC) and pedestrian-motor vehicle accidents (PMVA) who were admitted to the trauma center at Hamad general hospital, Doha, Qatar, between 2008 and 2011.

Results:

Of 5118 traumatic injury cases, 1004 (20%) were found to have BCT secondary to RTA (77% MVC and 23% PMVA). The majority were males (92%), and expatriates (72%). Among MVCs, 84% reported they did not use protective devices. There was a correlation between chest abbreviated injury score (AIS) and injury severity scoring (ISS) (r = 0.35, r² = 0.12, P < 0.001). Regardless of mechanism of injury (MOI), multivariate analysis showed that the head injury associated with chest AIS and ISS was a predictor of mortality in BCT. Overall mortality was 15%, and the highest rate was observed within the first 24 hours post-trauma.

Conclusions:

Blunt chest trauma from RTA represents one-fifth of the total trauma admissions in Qatar, with a high overall mortality. Pedestrians are likely to have more severe injuries and higher fatality rates than MVC victims. Specific injury prevention programs focusing on road safety should be implemented to minimize the incidence of such preventable injuries.

Management of Blunt Pulmonary Injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Hemothorax after the intravenous administration of tissue plasminogen activator in a patient with acute ischemic stroke and rib fractures

A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic stroke in the territory of the right middle cerebral artery. He underwent systemic thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest radiography and computed tomography performed the following day showed severe hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest radiogram had revealed rib fractures but we did not recognize them at the time. Conservative treatment with the placement of chest tubes was successful, and the patient recovered without further deterioration. Although systemic thrombolysis with t-PA is an accepted treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the literature found no reports of hemothorax after treatment with t-PA in patients with cerebral ischemic stroke. We have reported a rare case of severe hemothorax after systemic thrombolysis with t-PA. This important complication indicates the need to rule out thoracic trauma with radiography and computed tomography of the chest.

Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography

Background

Rib series (RS) are a special radiological technique to improve the visualization of the bony parts of the chest.

Objectives

The aim of this study was to evaluate the diagnostic accuracy of rib series in minor thorax trauma.

Methods

Retrospective study of 56 patients who received RS, 39 patients where additionally evaluated by plain chest film (PCF). All patients underwent a computed tomography (CT) of the chest. RS and PCF were re-read independently by three radiologists, the results were compared with the CT as goldstandard. Sensitivity, specificity, negative and positive predictive value were calculated. Significance in the differences of findings was determined by McNemar test, interobserver variability by Cohens kappa test.

Results

56 patients were evaluated (34 men, 22 women, mean age =61 y.). In 22 patients one or more rib fracture could be identified by CT. In 18 of these cases (82%) the correct diagnosis was made by RS, in 16 cases (73%) the correct number of involved ribs was detected. These differences were significant (p = 0.03). Specificity was 100%, negative and positive predictive value were 85% and 100%. Kappa values for the interobserver agreement was 0.92-0.96. Sensitivity of PCF was 46% and was significantly lower (p = 0.008) compared to CT.

Conclusions

Rib series does not seem to be an useful examination in evaluating minor thorax trauma. CT seems to be the method of choice to detect rib fractures, but the clinical value of the radiological proof has to be discussed and investigated in larger follow up studies.

Factors associated with intensive care unit admission in patients with traumatic thoracic injury

OBJECTIVE

To identify factors associated with intensive care unit (ICU) admission in patients with traumatic thoracic injury.

METHODS

Data for consecutive patients with thoracic trauma were collected prospectively. Outcomes were requirement for ICU care and prolonged (>7 days) ICU care.

RESULTS

The study included 1333 patients, 484 (36.3%) of whom received ICU care: 125 of these (25.8%) received prolonged ICU care. Head injury, abdominal injury, injury severity score ≥ 16, haemothorax, chest tube placement and spinal surgery were significantly associated with ICU care. Head injury, number of rib fractures, chest drain placement, spinal surgery and extremity surgery were independent risk factors for prolonged ICU care.

CONCLUSIONS

Associated injury factors played a more prominent role than thoracic factors in the need for ICU and prolonged ICU care. A multidisciplinary trauma team (involving neurosurgeons, abdominal surgeons, orthopaedic surgeons and thoracic surgeons) is essential for the care of patients with traumatic thoracic injury.

Emergency thoracotomies: Two center study

Introduction and Aim:

Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors.

Patients and Methods:

Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis.

Results:

Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures.

Conclusion:

The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory support. Emergency thoracotomy has an important role in emergency big volume hospitals and can save a lot of lives. Outcome can be improved by increasing the learning curve and the integrated cooperation of the emergency and surgical teams.

[Chest trauma: who, how and what?]

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

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

Background

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

Methods

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

Results

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

Conclusions

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

Initial management and resuscitation of severe chest trauma

Severe chest trauma, blunt or penetrating, is responsible for up to 25% of traumatic deaths in North America. Respiratory compromise is the most frequent dramatic presentation in blunt trauma, while injuries to the heart and great vessels pose the greatest risk of immediate death following penetrating trauma. More than 80% of patients will be managed with interventions that can be performed in the emergency department. This article reviews the presentation, diagnosis, and management of the most important thoracic injuries. A structured approach to the acutely unstable patient is proposed to guide resuscitation decisions.

Anaesthetic and critical care management of thoracic injuries

Thoracic wounding has been a relatively common presentation of military wounds throughout modern conflict. When civilian casualties are included the incidence has remained constant at around 10%, although the frequency and severity of wounds to combatants has been altered by modern body armour. Whilst thoracic injury has a high initial mortality on the battlefield, those surviving to reach hospital frequently have injuries that only require simple management. In addition to penetrating ballistic injury, blunt chest trauma frequently occurs on operations as a result of road traffic collisions or tertiary blast injury. The physiological impact of thoracic wounds, however, is often great and survivors often require intensive care management and, where available, complex strategies to ensure oxygenation and carbon dioxide removal. This review examines the incidence and patterns of thoracic trauma and looks at therapeutic options for managing these complex cases.