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Caputo G, Meda S, Piccioni A, Saviano A, Ojetti V, Savioli G, Piccini GB, Ferrari C, Voza A, Pellegrini L, Ottaviani M, Spadazzi F, Volonnino G, La Russa R. Thoracic Trauma: Current Approach in Emergency Medicine. Clin Pract 2024; 14:1869-1885. [PMID: 39311298 PMCID: PMC11417912 DOI: 10.3390/clinpract14050148] [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: 01/26/2024] [Revised: 07/05/2024] [Accepted: 07/26/2024] [Indexed: 09/26/2024] Open
Abstract
Chest trauma is the leading cause of death in people under 40. It is estimated to cause around 140,000 deaths each year. The key aims are to reduce mortality and the impact of associated complications to expedite recovery and to restore patient's conditions. The recognition of lesions through appropriate imaging and early treatment already in the emergency department are fundamental. The majority can be managed in a non-surgical way, but especially after traumatic cardiac arrest, a surgical approach is required. One of the most important surgical procedures is the Emergency Department Thoracotomy (EDT). The aim of this review is to provide a comprehensive synthesis about the management of thoracic trauma, the surgical procedures, accepted indications, and technical details adopted during the most important surgical procedures for different thoracic trauma injuries. Literature from 1990 to 2023 was retrieved from multiple databases and reviewed. It is also important to emphasize the medico-legal implications of this type of trauma, both from the point of view of collaboration with the judicial authority and in the prevention of any litigation.
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Affiliation(s)
- Giorgia Caputo
- Division of Anesthesia and Critical Care, Santi Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy;
| | - Stefano Meda
- Division of Thoracic Surgery, Santi Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy;
| | - Andrea Piccioni
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (A.P.); (A.S.)
| | - Angela Saviano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (A.P.); (A.S.)
| | - Veronica Ojetti
- Internal Medicine Department, San Carlo di Nancy Hospital, 00165 Rome, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | | | - Chiara Ferrari
- Division of Anesthesia, Intensive Care, Pain Medicine, Policlinico Hospital, 70124 Bari, Italy;
| | - Antonio Voza
- Emergency Medicine, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Lavinia Pellegrini
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (L.P.); (M.O.); (F.S.); (G.V.)
| | - Miriam Ottaviani
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (L.P.); (M.O.); (F.S.); (G.V.)
| | - Federica Spadazzi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (L.P.); (M.O.); (F.S.); (G.V.)
| | - Gianpietro Volonnino
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (L.P.); (M.O.); (F.S.); (G.V.)
| | - Raffaele La Russa
- Department of Clinical Medicine, Public Health, Life Sciences, Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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Heo S, Kim JH, Jung Y, Lee K, Lee S, Yi E. Clinical Experience of Surgical Treatment for Penetrating Pulmonary Gunshot Wound of a Civilian in Korea: A Case Report. J Chest Surg 2024; 57:87-91. [PMID: 37574883 DOI: 10.5090/jcs.23.061] [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: 05/15/2023] [Revised: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Gunshot-induced chest trauma is exceedingly rare among civilians in South Korea due to strong firearm control policies. In contrast to military reports emphasizing the use of emergent open thoracotomy to increase chances of survival, most penetrating non-cardiac injuries in civilian settings are managed conservatively, such as through chest tube insertion, as they typically result from lower-energy bullets. However, early surgical intervention for penetrating gunshot wounds can help reduce delayed fatalities caused by septic complications from pneumonia or empyema. The advent of minimally invasive thoracic surgery has provided cost-effective and relatively non-invasive treatment options, aided in the prevention of potential complications from undrained hematomas, and facilitated functional recovery and reintegration into society. We successfully treated a patient with a penetrating gunshot wound to the chest using video-assisted thoracoscopic surgery.
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Affiliation(s)
- Seonyeong Heo
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Jung Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Younggi Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Kwanghyoung Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Sungho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Eunjue Yi
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
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Sozzi M, Inaba K, Schellenberg MA, Matsushima K, Martin MJ. Dangerous passage: the utility and accuracy of modern chest computed tomography in penetrating thoracic injuries with potential transmediastinal trajectory. Eur J Trauma Emerg Surg 2023; 49:2439-2445. [PMID: 37358631 PMCID: PMC10728241 DOI: 10.1007/s00068-023-02315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
AIM The aim of this study is to evaluate utility and reliability of chest CT as a standalone screening modality for stable patients with thoracic GSWs and potential transmediastinal trajectories. METHODS All patients with thoracic GSWs over a 5-year period were identified. Unstable patients requiring immediate surgery were excluded and the remaining underwent chest CT with intravenous contrast. Sensitivity and specificity for clinically significant injuries were tested against an aggregate gold standard of discharge diagnosis including imaging, operative and clinical findings. RESULTS A total of 216 patients met inclusion criteria and underwent chest CT. After imaging, 65 (30.1%) had indication for immediate surgery, of which 10 (4.6%) underwent a thoracic procedure for chest injuries while 151 (69.9%) were selected for nonoperative management (NOM). 11 (5.1%) required a delayed thoracic operation, none due to injuries missed on CT. The remaining 140 (64.8%) underwent successful NOM. Up to 195 (90.3%) patients had successful NOM of thoracic injuries. Only 9.2% required additional imaging, all negative. CT identified a cardiac injury in one case and a vascular injury in two cases, all confirmed by surgery, while one thoracic IVC injury missed on CT was found intraoperatively. 2 patients had CT suspicious for esophageal injury, ruled out by following investigations. There was one death in the total cohort, none in the NOM group. CONCLUSIONS Modern high-quality CT provides highly accurate and reliable screening modality for penetrating chest and mediastinal injuries and can be used as a standalone study in most patients or to guide further tests. Chest CT facilitated successful NOM.
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Affiliation(s)
- Marco Sozzi
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA.
| | - Kenji Inaba
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Morgan A Schellenberg
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Matthew J Martin
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
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Sozzi M, Wu Y, Matsushima K, Schellenberg M, Inaba K, Martin M. Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma. Am Surg 2023; 89:4018-4024. [PMID: 37165630 DOI: 10.1177/00031348231175451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults. METHODS Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management. RESULTS Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation. CONCLUSION Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.
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Affiliation(s)
- Marco Sozzi
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Yutung Wu
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Morgan Schellenberg
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Kenji Inaba
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Matthew Martin
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
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Elkbuli A, Newsome K, Fanfan D, Sutherland M, Bilski T, Liu H, Ang D. Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients with Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset. Am Surg 2022; 88:2182-2193. [PMID: 35592893 DOI: 10.1177/00031348221101510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients. METHODS Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed. RESULTS Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001). CONCLUSIONS Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Kevin Newsome
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Dino Fanfan
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Mason Sutherland
- 2814NSU NOVA Southeastern University, Dr. Kiran.C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of South Florida, Tampa, FL, USA
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García Franco C, Altaf F, Gharbi M. HOW TO APPROACH A MEDIASTINAL FIREARM WOUND: THE ROLE OF CONSERVATIVE MANAGEMENT AND VATS SURGERY. Arch Bronconeumol 2022; 58:708-709. [DOI: 10.1016/j.arbres.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 11/02/2022]
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Ichinokawa H, Konishi Y, Uchida S, Suzuki K. Penetrating chest trauma in Sauer's danger zone without serious heart or lung damage: An unusual case report. Int J Surg Case Rep 2022; 92:106843. [PMID: 35202936 PMCID: PMC8881475 DOI: 10.1016/j.ijscr.2022.106843] [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: 12/31/2021] [Revised: 01/28/2022] [Accepted: 02/13/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction and importance Case presentation Clinical discussion Conclusion The area where there is a risk of cardiovascular injury is called Sauer's danger zone. The amount of bleeding in the drain was an indicator of non-macrovascular injury. There is a discrepancy between chest CT and surgical findings. Chest tube drainage and hemodynamics should always be observed. The potential need for emergency surgery should be kept in mind.
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Affiliation(s)
- Hideomi Ichinokawa
- Department of General Thoracic Surgery, Juntendo University Hospital, Tokyo, Japan.
| | - Yasuhito Konishi
- Department of General Thoracic Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Sinsuke Uchida
- Department of General Thoracic Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University Hospital, Tokyo, Japan
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Robinson B, Purcell LN, Kajombo C, Gallaher J, Charles A. Outcomes of stab wounds presenting to Kamuzu Central Hospital in Malawi. Malawi Med J 2021; 33:1-6. [PMID: 34422227 PMCID: PMC8360291 DOI: 10.4314/mmj.v33i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Injuries are a leading cause of morbidity and mortality worldwide, necessitating that we understand the local burden of injury to improve injury-related trauma care and patient outcomes. The characteristics, outcomes, and risk factors for mortality following stab wounds in Malawi are poorly delineated. Methods This is a retrospective, descriptive analysis of patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, with stab wounds from February 2008 to May 2018. Univariate and bivariate analyses were performed to compare patient and injury characteristics based on mortality. We performed Poisson multivariate regression to predict the factors that increase the relative risk of mortality. Results During the study, 32,297 patients presented with assault. Of those patients, 2,352 (7.3%) presented with stab wounds resulting in a 3.2% (n=74) overall mortality. The majority of wounds were to the head or cervical spine (n=1,043, 44.6%), while injuries to the chest (n=319, 13.7%) were less frequent. We found an increased relative risk of mortality in patients who presented with an injury to the chest (RR 3.95, 95% CI 1.79-8.72, p=0.001) and who were brought in by the police (RR 33.24, 95% CI 11.23-98.35, p<0.001). Conclusion In this study, stab wounds accounted for 7.3% of all assault cases, with a 3.2% mortality. Though the commonest site of stab was the head, wounds to the chest conferred the highest relative risk of mortality. A multifaceted approach to reducing mortality is needed. Incorporating training of first responders in basic life support, including the police, may reduce stab-related mortality.
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Affiliation(s)
- Brittany Robinson
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill
| | | | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill
- Kamuzu Central Hospital, Lilongwe, Malawi
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Kawamoto N, Okita R, Furukawa M, Inokawa H, Hayashi M, Okada M, Okabe K. Penetrating pulmonary injury due to a thrown rusty nail while using a lawn mower: a case report. AME Case Rep 2020; 4:35. [PMID: 33179007 DOI: 10.21037/acr-20-87] [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: 05/04/2020] [Accepted: 08/27/2020] [Indexed: 11/06/2022]
Abstract
Accidents while using lawn mowers are often reported, but chest injuries are rare. We report a case of a penetrating pulmonary injury due to a rusty nail thrown by a lawn mower. A 63-year-old man injured his left precordium by a thrown object while using a lawn mower; he thereafter visited a nearby hospital. A computed tomography image showed a left-sided pneumothorax and a penetrating pulmonary injury of the left upper lobe due to a foreign body. Pneumothorax was treated with thoracic drainage and resolved. He was transferred to our hospital on the second day after the injury, and video-assisted thoracoscopic surgery was performed to remove the foreign body. Surgical findings showed a penetrating wound in the left upper lobe and leakage of pus from its margin. The foreign body was a rusty nail. The penetrating wound was treated by partial pulmonary resection to control the infection. Histopathological findings revealed the formation of a lung abscess. Penetrating pulmonary injuries do not require surgical treatment for most patients. However, residual foreign bodies can cause lung abscesses. The removal of foreign bodies depends on the type of injury as well as the type and location of the foreign body. Theoretically, the foreign body should be removed and the penetrating pulmonary injury should be treated, if possible, to control infection.
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Affiliation(s)
- Nobutaka Kawamoto
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Riki Okita
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Masashi Furukawa
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Hidetoshi Inokawa
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Masataro Hayashi
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Masanori Okada
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
| | - Kazunori Okabe
- Department of Thoracic Surgery, National Hospital Organization Yamaguchi Ube Medical Center, Ube, Yamaguchi, Japan
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Successful treatment and survival after gunshot wound to the aortic arch with bullet embolism to superficial femoral artery. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:283-288. [PMID: 31309169 PMCID: PMC6606949 DOI: 10.1016/j.jvscit.2019.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/27/2019] [Indexed: 11/21/2022]
Abstract
Mortality after gunshot wounds to the thoracic aorta ranges from 92% to 100%. Survival is almost always in patients with injury from low-caliber, low-velocity bullets with hemorrhage contained by the wall of the aorta. Bullet embolization, even rarer with a reported incidence of 0.3% of vascular injuries, is most commonly found during autopsy. We report the successful treatment and survival of a patient who presented with a large-caliber gunshot wound to the aortic arch with contained rupture and bullet embolization from the aortic arch to the superficial femoral artery. The patient remained functionally independent and was discharged without complication.
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Fu CY, Bajani F, Tatebe L, Butler C, Starr F, Dennis A, Kaminsky M, Messer T, Schlanser V, Kramer K, Poulakidas S, Cheng CT, Mis J, Bokhari F. Right hospital, right patients: Penetrating injury patients treated at high-volume penetrating trauma centers have lower mortality. J Trauma Acute Care Surg 2019; 86:961-966. [PMID: 31124893 DOI: 10.1097/ta.0000000000002245] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The recognition of the relationship between volume and outcomes led to the regionalization of trauma care. The relationship between trauma mechanism-subtype and outcomes has yet to be explored. We hypothesized that trauma centers with a high volume of penetrating trauma patients might be associated with a higher survival rate for penetrating trauma patients. METHODS A retrospective cohort analysis of penetrating trauma patients presenting between 2011 and 2015 was conducted using the National Trauma Database and the trauma registry at the Stroger Cook County Hospital. Linear regression was used to determine the relationship between mortality and the annual volume of penetrating trauma seen by the treating hospital. RESULTS Nationally, penetrating injuries account for 9.5% of the trauma cases treated. Patients treated within the top quartile penetrating-volume hospitals (≥167 penetrating cases per annum) are more severely injured (Injury Severity Score: 8.9 vs. 7.7) than those treated at the lowest quartile penetrating volume centers (<36.6 patients per annum). There was a lower mortality rate at institutions that treated high numbers of penetrating trauma patients per annum. A penetrating trauma mortality risk adjustment model showed that the volume of penetrating trauma patients was an independent factor associated with survival rate. CONCLUSION Trauma centers with high penetrating trauma patient volumes are associated with improved survival of these patients. This association with improved survival does not hold true for the total trauma volume at a center but is specific to the volume of the penetrating trauma subtype. LEVEL OF EVIDENCE Prognostic/Epidemiology Study, Level-III; Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Chih-Yuan Fu
- From the Department of Trauma and Burn Surgery (C-Y.F., F.B., L.T., C.B., F.S., A.D., M.K., T.M., V.S., K.K., S.P. C-T.C., J.M., F.B.), Stroger Hospital of Cook County, Rush University, Chicago, Illinois; and Department of Trauma and Emergency Surgery (C-Y.F., C-T.C.), Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
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Rupprecht H, Gaab K. Large thoracic defect due to shotgun violation - surgical emergency management. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2017; 6:Doc14. [PMID: 28868228 PMCID: PMC5566116 DOI: 10.3205/iprs000116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Shotgun injuries from a short distance (<3 m) may cause massive bleeding and tissue destruction. Only immediate aggressive (surgical) therapy prevents lethal outcome. We report about a 27-year-old patient, who was wounded on the left chest wall by a straight-cut shotgun from a short distance. In cases of this special traumatic pattern damage control measures are necessary. The measures should take place in preclinical emergency management (by the on-site emergency physician). We report about the emergency management from admission to our hospital and the following surgical treatment until discharge from the hospital.
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Affiliation(s)
- Holger Rupprecht
- Klinikum Fürth, Department of Visceral, Thoracic, and Vascular Surgery, Fürth, Germany
| | - Katharina Gaab
- Klinikum Fürth, Department of Visceral, Thoracic, and Vascular Surgery, Fürth, Germany
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Boldyrev SY, Kibirov RI, Danilov VV, Nirov RD, Porkhanov VA. [Successful repair of ascending aortic stab wound]. Khirurgiia (Mosk) 2017:83-84. [PMID: 28303879 DOI: 10.17116/hirurgia2017283-84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S Yu Boldyrev
- Research Institute "Regional Clinical Hospital #1', Krasnodar; Chair of Oncology with the course of Thoracic Surgery and Chair of Cardiac Surgery and Cardiology, Kuban State Medical University
| | - R I Kibirov
- Research Institute "Regional Clinical Hospital #1', Krasnodar
| | - V V Danilov
- Research Institute "Regional Clinical Hospital #1', Krasnodar
| | - R D Nirov
- Research Institute "Regional Clinical Hospital #1', Krasnodar
| | - V A Porkhanov
- Research Institute "Regional Clinical Hospital #1', Krasnodar; Chair of Oncology with the course of Thoracic Surgery and Chair of Cardiac Surgery and Cardiology, Kuban State Medical University
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Abstract
The management of gunshot wounds is an increasing problem for UK emergency doctors, but not to an extent where it has become routine or allowed individuals to gain significant experience in their treatment. This article reviews the pathophysiology of gunshot injury in general before examining the evidence available concerning the management of gunshot wounds to the head neck and thorax.
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Affiliation(s)
- Jeff Garner
- Chesterfield Royal Hospital, Calow, Chesterfield, Derbyshire, UK,
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Abstract
Penetrating chest trauma occurs worldwide, and various accounts of it have been reported in the literature. 1 – 5 Blunt trauma is not usually associated with military or civilian violence, while penetrating chest trauma often is. Penetrating chest trauma is frequently caused by gunshots and non gunshot-related incidents such as stabs, traffic accidents, and impalements. This prospective study was conducted to determine a pattern of penetrating thoracic injuries, including their causes, the role of surgery, and intervention outcomes. In this study, we treated 168 patients (142 males and 26 females, giving a male-to-female ratio of 5.5:1). Gunshots caused 60.1% of the injuries while traffic accidents caused 27.3% of the injuries. Chest tube insertion alone was the main treatment initiated. This technique was used on 73.8% of the patients. To reduce the occurrence of penetrating chest trauma in Lagos, Nigeria, study results suggest that the Nigerian people and their property need greater security, and that pre-hospital level of care for trauma victims must improve.
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Affiliation(s)
- Martins O Thomas
- Cardiothoracic Surgery Unit, Lagos University Teaching Hospital, College of Medicine of University of Lagos, Lagos, Nigeria
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Mitchell J, Bogar L, Burton N. Cardiothoracic surgical emergencies in the intensive care unit. Crit Care Clin 2015; 30:499-525. [PMID: 24996607 DOI: 10.1016/j.ccc.2014.03.004] [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: 11/30/2022]
Abstract
Patients with cardiothoracic surgical emergencies are frequently admitted to the ICU, either prior to operative intervention or after surgery. Recognition and appropriate timing of operative intervention are key factors in improving outcomes. A collaborative team approach with the cardiothoracic service is imperative in managing this patient population.
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Affiliation(s)
- Jessica Mitchell
- Department of Critical Care Medicine, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Linda Bogar
- Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA; Cardiac Vascular & Thoracic Surgery Associates, Inova Fairfax Hospital, 2921 Telestar Court, Falls Church, VA 22042, USA
| | - Nelson Burton
- Cardiac Vascular & Thoracic Surgery Associates, Inova Fairfax Hospital, 2921 Telestar Court, Falls Church, VA 22042, USA
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Kong VY, Sartorius B, Clarke DL. The selective conservative management of penetrating thoracic trauma is still appropriate in the current era. Injury 2015; 46:49-53. [PMID: 25102807 DOI: 10.1016/j.injury.2014.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 06/02/2014] [Accepted: 07/11/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic pleural collections secondary to penetrating chest trauma are generally managed by intercostal chest drainage (ICD), but these protocols were developed a few decades ago when stabs (SWs) predominated over gunshot wounds (GSWs). This study reviews the outcome of a selective conservative approach to penetrating thoracic trauma to establish if it is still appropriate in the current era. MATERIALS AND METHODS We reviewed 827 patients over a four-year period with penetrating unilateral non-cardiac wounds of the chest in order to review the efficacy of our policy and to define the differences in the spectrum of injury between SWs and GSWs. RESULTS Ninety-two per cent (764/827) were males, and the median age was 24 years. Seventy-six per cent (625/827) sustained SWs and twenty-four per cent (202/827) GSWs. Chest pathologies were: pneumothorax (PTX): 362 (44%), haemothorax (HTX): 150 (18%) and haemopneumothorax (HPTX): 315 (38%). Ninety-six per cent of patients were managed non-operatively. Four per cent (36/827) were subjected to a thoracotomy [31 SWs and 5 GSWs]. No difference was observed in terms of the need for operative intervention: 5% vs. 3% [p=0.202]. PTX was seen exclusively in SWs: 58% vs. 0% and there were significantly more HPTXs seen in the GSWs: HPTX: 24% vs. 81% [p<0.001]. The median days of ICD in situ were significantly longer in GSWs compared to SWs for all pathologies. For HTX: 4.5 (interquartile range [IQR]: 3-6) vs. 3.5 (IQR: 0-5) days, p=0.001 and HPTX: 4 (IQR: 3-5) vs. 3.0 (IQR: 3-4) days, p<0.001. There were seven (15%) complications. A total of five (13%) patients died and all deaths were confined to the operative group. CONCLUSIONS SWs continue to predominate over GSWs. PTXs were more commonly associated with SWs, whilst HPTX are more commonly associated with GSWs. A policy of selective conservatism is still applicable to the management of traumatic pleural collections.
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Affiliation(s)
- Victor Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg 3216, South Africa.
| | - Benn Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - Damian L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg 3216, South Africa.
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The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 2014; 77:684-691. [PMID: 25494418 DOI: 10.1097/ta.0000000000000436] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thoracoabdominal firearm injuries present major diagnostic and therapeutic challenges because of the risk for potential injury in multiple anatomic cavities and the attendant dilemma of determining the need for and correct sequencing of cavitary intervention. Injury patterns, management strategies, and outcomes of thoracoabdominal firearm trauma remain undescribed across a large population. METHODS All patients with thoracoabdominal firearm injury admitted to a major Level I trauma center during a 16-year period were reviewed. RESULTS The 984 study patients experienced severe injury burden; 25% (243 of 984) presented in cardiac arrest, and 75% (741 of 984) had an Abbreviated Injury Scale (AIS) score of 3 or greater in both the chest and the abdomen. Operative management occurred in 86% (638 of 741). Of the patients arriving alive, 68% (507 of 741) underwent laparotomy alone, 4% (27 of 741) underwent thoracotomy alone, and 14% (104 of 741) underwent dual-cavitary intervention. Negative laparotomy occurred in 3%. Diaphragmatic injury (DI) occurred in 63%. Seventy-five percent had either DI or hollow viscus injury. Cardiac injury was present in 33 patients arriving alive. Despite the use of trauma bay ultrasound, 44% of the patients with cardiac injury underwent initial laparotomy. In half of this group, ultrasound did not detect pericardial blood. The need for thoracotomy, either alone or as part of dual-cavitary intervention, was the strongest independent risk factor for mortality in those arriving alive. CONCLUSION Greater kinetic destructive potential drives the peril of thoracoabdominal firearm trauma, producing clinical challenges qualitatively and quantitatively different from nonfirearm injuries. Severe injury, on both sides of the diaphragm, generates high operative need with low rates of negative exploration. The need for emergent intervention and a high incidence of DI or hollow viscus injury limit opportunity for nonoperative management. Even with ultrasound, emergent preoperative diagnosis remains challenging, as the complex combination of intra-abdominal, thoracic, and diaphragmatic injuries can provoke misinterpretation of both radiologic and clinical data. Successful emergent management requires thorough assessment of all anatomic spaces, integrating ultrasonographic, radiologic, and clinical findings. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Kuhajda I, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Zaric B, Branislav P, Dervelegas K, Porpodis K, Zarogoulidis P. Penetrating trauma. J Thorac Dis 2014; 6:S461-5. [PMID: 25337403 DOI: 10.3978/j.issn.2072-1439.2014.08.51] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 08/26/2014] [Indexed: 12/13/2022]
Abstract
Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.
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Affiliation(s)
- Ivan Kuhajda
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Ioanna Kougioumtzi
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Haidong Huang
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Qiang Li
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Georgios Dryllis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Ioannis Kioumis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Georgia Pitsiou
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Nikolaos Machairiotis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Antonis Papaiwannou
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Sofia Lampaki
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Bojan Zaric
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Perin Branislav
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Konstantinos Dervelegas
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Konstantinos Porpodis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 8 Radiology Department, "Hipokratio" University General Hospital, Thessaloniki, Greece
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Transmediastinal and transcardiac gunshot wound with hemodynamic stability. Case Rep Surg 2014; 2014:985097. [PMID: 25197606 PMCID: PMC4150517 DOI: 10.1155/2014/985097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 08/05/2014] [Indexed: 11/18/2022] Open
Abstract
Cardiac injuries caused by knives and firearms are slightly increasing in our environment. We report the case of a 43-year-old male patient with a transmediastinal gunshot wound (TGSW) and a through-and-through cardiac wound who was hemodynamically stable upon his admission. He had an entrance wound below the left clavicle, with no exit wound, and decreased breath sounds in the right hemithorax. Chest X-ray showed the bullet in the right hemithorax and large right hemothorax. The ultrasound revealed pericardial effusion, and a chest tube produced 1500 cc. of blood, but he remained hemodynamically stable. Considering these findings, a median sternotomy was carried out, the through-and-through cardiac wounds were suture-repaired, lung laceration was sutured, and a pacemaker was placed in the right ventricle. The patient had uneventful recovery and was discharged home on the twelfth postoperative day. The management and prognosis of these patients are determined by the hemodynamic situation upon arrival to the Emergency Department (ED), as well as a prompt surgical repair if needed. Patients with a TGSW have been divided into three groups according to the SBP: group I, with SBP >100 mmHg; group II, with SBP 60–100 mmHg; and group III, with SBP <60 mmHg. The diagnostic workup and management should be tailored accordingly, and several series have confirmed high chances of success with conservative management when these patients are hemodynamically stable.
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Munsterman AS, Hanson RR. Trauma and wound management: gunshot wounds in horses. Vet Clin North Am Equine Pract 2014; 30:453-66, ix. [PMID: 25016502 DOI: 10.1016/j.cveq.2014.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Bullet wounds in horses can cause a wide array of injuries, determined by the type of projectile, the energy of the bullet on entry, and the type of tissue the bullet encounters. Treatment includes identification of all structures involved, debridement of the permanent cavity, and establishing adequate drainage. Bullet wounds should be treated as contaminated, and broad-spectrum antibiotics, including those with an anaerobic spectrum, are indicated. Although musculoskeletal injuries resulting from gunshots are most common in horses, they carry a good prognosis for survival and return to function.
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Affiliation(s)
- Amelia S Munsterman
- Department of Clinical Sciences, J.T. Vaughan Large Animal Teaching Hospital, Auburn University College of Veterinary Medicine, 1500 Wire Road, Auburn, AL 36849, USA.
| | - R Reid Hanson
- Department of Clinical Sciences, J.T. Vaughan Large Animal Teaching Hospital, Auburn University College of Veterinary Medicine, 1500 Wire Road, Auburn, AL 36849, USA
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Bradley M, Okoye O, DuBose J, Inaba K, Demetriades D, Scalea T, O'Connor J, Menaker J, Morales C, Shiflett T, Brown C. Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study. Injury 2013; 44:1159-64. [PMID: 23433600 DOI: 10.1016/j.injury.2013.01.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/11/2013] [Accepted: 01/19/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH. METHODS We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived. RESULTS 328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH. CONCLUSIONS To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.
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Affiliation(s)
- Matthew Bradley
- Department of Trauma and Surgical Critical Care, University of Maryland Medical System/R Adams Cowley Shock Trauma, Baltimore, MD 21201, USA.
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Bertolaccini L, Rizzardi G, Filice MJ, Spada E, Terzi A. The "ending neglect" of roentgenograms in penetrating chest trauma. J Thorac Dis 2012; 2:197-8. [PMID: 22263046 DOI: 10.3978/j.issn.2072-1439.2010.02.04.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 10/04/2010] [Indexed: 11/14/2022]
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Al-Shaqsi S. Models of International Emergency Medical Service (EMS) Systems. Oman Med J 2011; 25:320-3. [PMID: 22043368 DOI: 10.5001/omj.2010.92] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 07/27/2010] [Indexed: 11/03/2022] Open
Affiliation(s)
- Sultan Al-Shaqsi
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Velik-Salchner C, Luckner G, Lorenz I, Chevtchik O, Mair P. Pericardial tamponade from coronary artery laceration after thoracic spine surgery. J Cardiothorac Vasc Anesth 2010; 25:1095-7. [PMID: 21115362 DOI: 10.1053/j.jvca.2010.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Corinna Velik-Salchner
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University, Innsbruck, Austria.
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The Pattern of Thoracic Trauma After Suicide Terrorist Bombing Attacks. ACTA ACUST UNITED AC 2010; 69:1022-8; discussion 1028-9. [DOI: 10.1097/ta.0b013e3181f35c71] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Baydur A, Inaba K, Barmparas G, Teixeira P, Julianne A, Bukur M, Talving P, Demetriades D. Thoracic gunshot wounds: alterations to pulmonary function and respiratory muscle strength. THE JOURNAL OF TRAUMA 2010; 69:756-760. [PMID: 20938263 DOI: 10.1097/ta.0b013e3181ed4dbf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The impact on respiratory function of gunshot injuries to the chest is unknown. The objective is to assess pulmonary function and respiratory muscle strength (RMS) in patients who have recently sustained an isolated gunshot injury to the chest. METHODS After institutional review board approval, patients with isolated gunshot injuries to the chest were prospectively identified. Study patients underwent pulmonary function testing and an assessment of RMS and gas exchange. RESULTS Ten male patients sustaining an isolated pulmonary gunshot wound were prospectively enrolled with a mean age of 29 years ± 10 years and mean Injury Severity Score of 15 ± 5. All patients had an associated pneumothorax (n = 1), hemothorax (n = 4), or a combination of both (n = 5). After removal of all thoracostomy tubes and before discharge [7.4 days ± 5.4 days (range, 2-21 days)], patients underwent respiratory function testing. Lung volume subdivisions were reduced by 25% to 60% of predicted and diffusion capacity by 37% with preservation of the normal ratio of diffusion capacity to alveolar volume. In the six subjects able to perform spirometry in seated and supine postures, forced vital capacity decreased by 20% when changing posture (p = 0.046). Arterial blood gas analysis showed significant reduction in the P(AO)₂/FIO₂ ratio (or increase in AaDO₂). Maximal respiratory pressures were severely reduced from predicted values, the maximal inspiratory pressure by 60% and the maximal expiratory pressure by 78%. CONCLUSIONS Lung volumes and RMS are decreased moderately to severely in patients who have sustained an isolated pulmonary gunshot wound. Expiratory muscle force generation is more severely affected than inspiratory muscle force. Further investigation of the long-term impact of these injuries on respiratory function is warranted.
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Affiliation(s)
- Ahmet Baydur
- Divisions of Pulmonary, Keck School of Medicine, University of Southern California Medical Center, Los Angeles, California, USA.
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Abstract
About 15 % of war injuries involve the chest. Fortunately 85% of patients sustaining chest injuries that reach medical facility will require clinical observation or a simple procedure like tube thoracostomy. Only one in six patients has life-threatening injuries that necessitate urgent operative repair. Early deaths are caused by airway obstruction, major respiratory problems such as tension pneumothorax or massive hemothorax, and cardiac tamponade. These conditions are easily managed if recognized promptly. Diagnosis and management of various components of chest injury requires clear judgment and indepth knowledge of pathophysiological mechanisms involved. The therapeutic goal in the war scenario is to restore normal physiology and thereby to restore cardiac and pulmonary function and evacuate the patient after stabilization.
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Affiliation(s)
- Pvr Mohan
- Associate Professor, Department of Surgery, Armed Forces Medical College, Pune-40
| | - R Mohan
- Clinical Tutor, Department of Surgery, Armed Forces Medical College, Pune-40
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Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010; 18:35. [PMID: 20565804 PMCID: PMC2898680 DOI: 10.1186/1757-7241-18-35] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Accepted: 06/17/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. RESULTS Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference. CONCLUSION The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.
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Affiliation(s)
- Philipp Lichte
- Department of Trauma Surgery, University Hospital of the RWTH Aachen, Aachen, Germany.
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O'Connor J, Adamski J. The Diagnosis and Treatment of Non-Cardiac Thoracic Trauma. J ROY ARMY MED CORPS 2010; 156:5-14. [DOI: 10.1136/jramc-156-01-02] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Case of a 27-year-old man who sustained penetrating chest injury caused by a metallic (iron) bar projecting from a pillar of a construction after he fell down from a height.
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Affiliation(s)
- Hamid Al-Sayed
- Department of Thoracic Surgery, King Fahad Hospital, Almadinah Almunawarah, Medina, Saudi Arabia
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Talving P, DuBose J, Barmparas G, Inaba K, Demetriades D. Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents. Eur J Trauma Emerg Surg 2009; 35:225-39. [PMID: 26814899 DOI: 10.1007/s00068-008-8153-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 12/08/2008] [Indexed: 12/19/2022]
Abstract
Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.
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Affiliation(s)
- Peep Talving
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 9900, Los Angeles, CA, 90033, USA.
| | | | | | | | - Demetrios Demetriades
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA
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Velmahos GC, Butt MU. Cardiac and Pulmonary Injury. Eur J Trauma Emerg Surg 2008; 34:327. [PMID: 26815810 DOI: 10.1007/s00068-008-8099-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 07/02/2008] [Indexed: 11/28/2022]
Abstract
Cardiac and pulmonary injuries present major challenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these organs exist. Outcomes for severe injuries are still grave. Organized trauma systems can provide optimal care by minimizing prehospital time, allowing easy access to imaging modalities, and offering state-of-the-art treatment strategies. A multidisciplinary approach, including surgeons, intensivists, and others, is absolutely necessary.
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Affiliation(s)
- George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
| | - Muhammad U Butt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, MA, Boston, USA
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Abstract
Trauma is the leading cause of death in patients younger than 40 years of age. Thoracic injuries are common and often can be managed by tube thoracostomy. In many patients, however, the thoracic injuries must be repaired surgically in one of three time periods: immediate, urgent, or delayed thoracotomy. In this article, we describe the general approach to effectively managing thoracic trauma patients. We review common injuries and scenarios that may be encountered by the surgeon and discuss the considerations and variables that enter into the decision-making process for operative intervention.
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Affiliation(s)
- J Wayne Meredith
- Department of General Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Abstract
BACKGROUND Reports on the temporal evolution in lung resection are limited. To elucidate temporal changes in the demographics of lung resections, we analyzed nationally representative data that were collected for the National Hospital Discharge Survey from 1988 to 2002. METHODS Data collected between 1988 and 2002 were analyzed. Patients with International Classification of Diseases, ninth revision, clinical modification, procedure codes for lung resection were included in the sample. Three 5-year time periods were created (1988 to 1992, 1993 to 1997, and 1998 to 2002) to simplify the temporal analysis. Changes in the prevalence of procedures, age, gender, race, length of care, mortality, disposition status, and distribution by hospital size were evaluated. Trends in procedure-related complications were analyzed. RESULTS Between 1988 and 2002, a total of 512,758 lung resections were performed. Comparing the earliest to the most recent time period, we found increases in the average age (61.1 years [range, 1 to 89 years] vs 63.2 years [range, 1 to 91 years], respectively), in the proportion of patients who were female (40.1% vs 49.6%, respectively), and in the proportion of Medicare/Medicaid patients (43.8% vs 49%/4.7% vs 6.7%, respectively). Decreases in the average length of stay (12.9 days [range, 1 to 358 days] vs 9.1 days [range, 1 to 175 days], respectively) and in the proportion of patients discharged to their primary residence (86% vs 79.5%, respectively) were seen. The proportion of patients who had undergone lobectomies compared to other types of lung resection increased. Mortality rates were 5% vs 5.4%, respectively, while the frequency of complications decreased. CONCLUSION We identified temporal changes in lung resection surgery that may help in the construction of health-care policies to address the changing needs of and financial burdens on the health-care system.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical Center, Boston, MA, USA.
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Abstract
Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.
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Affiliation(s)
- H Schelzig
- Universitätsklinik für Thorax- und Gefässchirurgie, Universität Ulm.
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Katsaragakis S, Stamou KM, Androulakis G. Independent lung ventilation for asymmetrical chest trauma: effect on ventilatory and haemodynamic parameters. Injury 2005; 36:501-4. [PMID: 15755431 DOI: 10.1016/j.injury.2004.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2004] [Indexed: 02/02/2023]
Abstract
Complex thoracic injuries significantly alter the lung mechanics. There appears to be severe ventilation-perfusion inequality that is enhanced by the asymmetrical compliance of the injured areas. In cases of unilateral massive air leaks large tidal volumes are needed to deliver adequate air volume to the injured lung. In such cases, mechanical ventilation via a standard tracheal tube will direct a large fraction of the tidal volume to the less affected areas. An alternative means of ventilating these patients is the application of independent lung ventilation through a double lumen tracheal tube and the use of two separate ventilators. Two such cases are presented with emphasis given on the ventilatory and haemodynamic changes that were recorded.
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Affiliation(s)
- Stylianos Katsaragakis
- Surgical Intensive Care Unit, 1st Department of Surgery, Hippokrateion Hospital, 20 Potamianou Street, 115 28 Athens, Greece
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Zellweger R, Navsaria PH, Hess F, Omoshoro-Jones J, Kahn D, Nicol A. Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg 2004; 91:1619-23. [PMID: 15505872 DOI: 10.1002/bjs.4598] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to determine the incidence of thoracic sepsis following a systematic thoracic cavity washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma. METHODS Prospectively collected data on all patients presenting with penetrating thoracoabdominal trauma between July 1999 and July 2002 were analysed. Patients with peritoneal biliary-gastroenteric (BGE) contamination and a diaphragmatic laceration were managed by laparotomy and transdiaphragmatic thoracic lavage. RESULTS A total of 217 patients had penetrating thoracoabdominal injuries, of whom 110 had BGE contamination of the peritoneal cavity with spillage into the pleural cavity. The mean Injury Severity Score was 38.1. Gunshot and stab wounds occurred in 79 (71.8 per cent) and 31 (28.2 per cent) respectively. Contamination was from the stomach (55.4 per cent), large bowel (37.3 per cent), small bowel (29.1 per cent), gallbladder and bile ducts (9.1 per cent) and pancreas (6.4 per cent). Thoracic complications occurred in six patients (5.5 per cent): empyema in two, Escherichia coli-related pneumonia in three and pleuritis in one. There were no deaths. CONCLUSION A thoracic washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma and BGE contamination was associated with a low rate of intrathoracic septic complications.
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Affiliation(s)
- R Zellweger
- Department of General Surgery, Trauma Unit, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa
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Tayal VS, Beatty MA, Marx JA, Tomaszewski CA, Thomason MH. FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2004; 23:467-472. [PMID: 15098863 DOI: 10.7863/jum.2004.23.4.467] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. METHODS An observational prospective study was conducted over a 30-month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. RESULTS FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%-100%); specificity was 100% (95% confidence interval, 85.8%-100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%-99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%-100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false-positive results, giving a specificity of 100% (95% confidence interval, 85.8%-100%). This prompted necessary laparotomy in all 8. CONCLUSIONS In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.
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Affiliation(s)
- Vivek S Tayal
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina 28232, USA.
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Affiliation(s)
- Reuven Rabinovici
- Section of Trauma and Surgical Critical Care, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
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