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Helsloot D, Fitzgerald MC, Lefering R, Verelst S, Missant C. The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU. Eur J Anaesthesiol 2023; 40:865-873. [PMID: 37139941 PMCID: PMC10552823 DOI: 10.1097/eja.0000000000001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Up to 25% of trauma deaths are related to thoracic injuries. OBJECTIVE The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window. DESIGN Retrospective observational analysis. SETTING TraumaRegister DGU. PATIENTS Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related. MAIN OUTCOME MEASURES Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death. RESULTS Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n = 24 332) mortality was 5.9% ( n = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission. CONCLUSION About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths. TRIAL REGISTRATION The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.
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Affiliation(s)
- Dries Helsloot
- From the Department of Anaesthesiology & Emergency Medicine, AZ Groeninge Hospital (DH, CM), Department of Cardiovascular Sciences, KU Leuven University campus Kulak, Kortrijk, Belgium Kortrijk Campus, Kortrijk, Belgium (DH, CM), National Trauma Research Institute, Alfred Health & Monash University (DH, MCF), Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia (MCF), Institute for Research in Operative Medicine (IFOM), Universität Witten/Herdecke, Cologne, Germany (RL), Department of Emergency Medicine, UZ Leuven Hospital, (SV), Department of Public Health and Primary Care, KU Leuven University, Leuven, Belgium (SV), Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU)
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Hoepelman RJ, van der Linde RA, Beeres FJ, Beks RB, Sweet AA, Lansink KW, van Wageningen B, Tromp TN, Minervini F, Link BC, van Veelen NM, Hoogendoorn JM, de Jong MB, van Baal MC, Leenen LP, Groenwold RH, Houwert RM, IJpma FF. In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients. J Trauma Acute Care Surg 2023; 95:249-255. [PMID: 37165478 PMCID: PMC10389406 DOI: 10.1097/ta.0000000000004001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Clavicle and rib fractures are often sustained concomitantly. The combination of injuries may result in decreased stability of the chest wall, making these patients prone to (respiratory) complications and prolonged hospitalization. This study aimed to assess whether adding chest wall stability by performing clavicle fixation improves clinical outcomes in patients with concurrent clavicle and rib fractures. METHODS A prospective multicenter study was performed including all adult patients admitted between January 2018 and March 2021 with concurrent ipsilateral clavicle and rib fractures. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was hospital length of stay (HLOS). Secondary outcomes were intensive care unit length of stay, duration of mechanical ventilation, pain, complications, and quality of life at 6 weeks and 12 months of follow-up. RESULTS In total, 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was observed between clavicle plate fixation and HLOS (mean difference, 2.3 days; 95% confidence interval, -2.1 to 6.8; p = 0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which 5 underwent secondary clavicle fixation. CONCLUSION We found no evidence that, in patients with combined clavicle and multiple rib fractures, plate fixation of the clavicle reduces HLOS, pain, or (pulmonary) complications, nor that it improves quality of life. STUDY TYPE Therapeutic/Care Management; Level III.
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K A, S B, Govindarajalou R, Saya GK, Tp E, Rajendran G. Comparing Sensitivity and Specificity of Ultrasonography With Chest Radiography in Detecting Pneumothorax and Hemothorax in Chest Trauma Patients: A Cross-Sectional Diagnostic Study. Cureus 2023; 15:e44456. [PMID: 37791184 PMCID: PMC10544157 DOI: 10.7759/cureus.44456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background Thoracic trauma accounts for 20-25% of all traumas and is the third most frequent cause of death, after abdominal injury and head trauma. In the Emergency Department (ED), shifting an unstable patient to the X-ray room for detecting pneumothorax and hemothorax is always risky and bedside X-ray causes radiation exposure not only to the particular patient but also to the surrounding patients in a congested and busy ED. This can be avoided by using bedside ultrasonography (USG) as the initial imaging modality in chest trauma patients. Objective To compare the sensitivity and specificity of ultrasonography and chest radiography in detecting pneumothorax and hemothorax in chest trauma patients. Methods This cross-sectional diagnostic study was conducted for a period of one year at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, a tertiary care centre. All consecutive patients (n=255) with a suspected history of chest trauma were included in the study. The patients were evaluated bedside using USG by point of care ultrasonography trained emergency medicine physician and subsequently underwent chest radiography for documentation of pneumothorax and hemothorax. Sensitivity and specificity were calculated for ultrasonography and chest X-ray (CXR) compared with the composite gold standard (chest radiography and computed tomography thorax). Results Of the 255 patients, 89% were males. The mean age of the patients was 43.46 (standard deviation 16.3). Road traffic accident (RTA) was the most common mode of injury (81%). The median (interquartile range) time interval between injury and arrival at the hospital was four hours (2.5-7). About 16.1% of the patients had subcutaneous emphysema. About 88.2% of the patients were hemodynamically stable and 78% of the patients had associated other system injuries. The sensitivity and specificity of USG in detecting pneumothorax were 85.7% and 95.3% respectively and that of CXR were 71.4% and 100% respectively. Our study found that the sensitivity and specificity of USG in detecting hemothorax were 79% and 97.9% respectively and that of CXR were 62.9% and 100% respectively. Even in the subset of patients in whom a computed tomography scan was done, the sensitivity of USG was higher than that of CXR in detecting pneumothorax and hemothorax. The specificity of USG in detecting pneumothorax was the same as that of CXR and the specificity of USG in detecting hemothorax was higher than that of CXR in that subset of patients. Conclusion The sensitivities of USG in detecting pneumothorax and hemothorax were higher than that of CXR. The specificities of USG in detecting pneumothorax and hemothorax were comparable to that of CXR. Hence bedside USG performed by emergency physician during resuscitation helps in rapid diagnosis and early management of chest trauma patients.
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Affiliation(s)
- Aswin K
- Emergency Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, IND
| | - Balamurugan S
- General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Ramkumar Govindarajalou
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Ganesh Kumar Saya
- Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Elamurugan Tp
- General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gunaseelan Rajendran
- Emergency Medicine, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation, Puducherry, IND
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Lundin A, Akram SK, Berg L, Göransson KE, Enocson A. Thoracic injuries in trauma patients: epidemiology and its influence on mortality. Scand J Trauma Resusc Emerg Med 2022; 30:69. [PMID: 36503613 PMCID: PMC9743732 DOI: 10.1186/s13049-022-01058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality. METHODS Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality. RESULTS A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3). CONCLUSION Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.
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Affiliation(s)
- Andrea Lundin
- grid.24381.3c0000 0000 9241 5705Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, 171 64 Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Shahzad K. Akram
- grid.24381.3c0000 0000 9241 5705Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, 171 64 Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lena Berg
- grid.4714.60000 0004 1937 0626Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden ,grid.411953.b0000 0001 0304 6002School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Katarina E. Göransson
- grid.4714.60000 0004 1937 0626Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden ,grid.411953.b0000 0001 0304 6002School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Anders Enocson
- grid.24381.3c0000 0000 9241 5705Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, 171 64 Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Mistry R, Moore J. Management of blunt thoracic trauma. BJA Educ 2022; 22:432-439. [PMID: 36304913 PMCID: PMC9596286 DOI: 10.1016/j.bjae.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 10/31/2022] Open
Affiliation(s)
- R.N. Mistry
- Gold Coast University Hospital, Southport, QLD, Australia
| | - J.E. Moore
- Wellington Regional Hospital, Wellington, New Zealand
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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Benhamed A, Ndiaye A, Emond M, Lieutaud T, Boucher V, Gossiome A, Laumon B, Gadegbeku B, Tazarourte K. Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study. PLoS One 2022; 17:e0268202. [PMID: 35522686 PMCID: PMC9075643 DOI: 10.1371/journal.pone.0268202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries.
Methods
We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome.
Results
A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25–58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70–79 years age group, while this was observed in the 20–29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]).
Conclusion
Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.
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Affiliation(s)
- Axel Benhamed
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
- * E-mail:
| | - Amina Ndiaye
- IFSTTAR, Université Gustave Eiffel, Bron, France
| | - Marcel Emond
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | | | - Valérie Boucher
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Amaury Gossiome
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
| | | | | | - Karim Tazarourte
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
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Barea-Mendoza JA, Chico-Fernández M, Quintana-Díaz M, Pérez-Bárcena J, Serviá-Goixart L, Molina-Díaz I, Bringas-Bollada M, Ruiz-Aguilar AL, Ballesteros-Sanz MÁ, Llompart-Pou JA. Risk Factors Associated with Mortality in Severe Chest Trauma Patients Admitted to the ICU. J Clin Med 2022; 11:jcm11010266. [PMID: 35012008 PMCID: PMC8745825 DOI: 10.3390/jcm11010266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Jesús Abelardo Barea-Mendoza
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (J.A.B.-M.); (M.C.-F.)
| | - Mario Chico-Fernández
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (J.A.B.-M.); (M.C.-F.)
| | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma de Mallorca, Spain;
| | - Luís Serviá-Goixart
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, 25198 Lleida, Spain;
| | - Ismael Molina-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario Nuestra Señora de la Candelaria, 38010 Santa Cruz de Tenerife, Spain;
| | - María Bringas-Bollada
- Servicio de Medicina Intensiva, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain;
| | | | | | - Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma de Mallorca, Spain;
- Correspondence: ; Tel.: +34-871205974
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Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients. J Clin Med 2021; 10:jcm10194335. [PMID: 34640353 PMCID: PMC8509393 DOI: 10.3390/jcm10194335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
There has been an ongoing discussion as to which interventions should be carried out by an “organ specialist” (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.
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Davies J, Johnson R, Kashef E, Khan M, Dick E. How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408621995144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention. In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report. We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment.
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Affiliation(s)
- Joseph Davies
- Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK
| | - Rowena Johnson
- Nuffield Orthopaedic Centre, Oxford NHS Foundation Trust, Oxford, UK
| | - Elika Kashef
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK
| | - Elizabeth Dick
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review. J Clin Med 2021; 10:jcm10122733. [PMID: 34205701 PMCID: PMC8234368 DOI: 10.3390/jcm10122733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. MATERIALS AND METHODS Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. STUDY SELECTION Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. DATA EXTRACTION Two authors independently extracted data using a predesigned form. STATISTICS Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. RESULTS Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). CONCLUSIONS There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.
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Sweet AAR, Beks RB, IJpma FFA, de Jong MB, Beeres FJP, Leenen LPH, Houwert RM, van Baal MCPM. Epidemiology of combined clavicle and rib fractures: a systematic review. Eur J Trauma Emerg Surg 2021; 48:3513-3520. [PMID: 34075434 PMCID: PMC9532289 DOI: 10.1007/s00068-021-01701-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
Purpose The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. Methods A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant–Murley score, union and complications. Results Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56–60.6% versus 29% in patients without clavicle fractures. Vice versa, 14–18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days). Conclusion Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01701-4.
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Affiliation(s)
- Arthur A R Sweet
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands.
| | - Reinier B Beks
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank J P Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Mark C P M van Baal
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
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Pasquali GF, Kock KDS. Epidemiological profile of chest trauma and predictive factors for length of hospital stay in a hospital in Southern Brazil. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2021; 11:54-61. [PMID: 33824786 PMCID: PMC8012872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/26/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Thoracic trauma is one of the most common types, corresponding to 10% of the traumas admitted in emergency services. OBJECTIVE To analyse epidemiologic aspects of patients diagnosed with chest trauma in a hospital at the south of Brazil and its predictive factor for prolonged length of stay. METHODS We conducted a retrospective cohort involving patients who were victims of chest trauma. They were described by the International Classification of Diseases (ICD) from S20 to S29 admited in a regional hospital in Southern Brazil, from January 2008 to December 2018. The analysed variables were: sex, age, ICD, type of trauma, complication, need for intensive care unit (ICU), mechanical ventilation (MV) and oxygen therapy (O2), scores on Injury Severity Score (ISS) and Thoracic Trauma Severity Score (TTSS) and outcomes length of stay and death. RESULTS 121 patients were evaluated, with median age 47.0 (35-0-58.5) years, where 84.3% being of them were male. Blunt trauma had a higher prevalence with 85.1%, with the most frequent complication being spine fractures (30.4%), followed by rib fractures (23.2%) and pneumothorax (16.8%). There was need of ICU in 14%, use of O2 in 30.6% and need of MV in 5.8%. The median length of stay was 6.0 (4.0-10.5), and death as an outcome was found in only 1.7%. Relying on the TTSS, the median (p25-p75) found was 3.0 (2.0-5.0) points and the ISS score was 4.0 (0.0-9.0). If observing patients with a length of stay ≥ 6 days, there were an association with the female gender, need of ICU, O2 and MV, ISS scores, and TTSS scores in the categories who involved pleural commitment and minor PaO2/FiO2. CONCLUSION Most of the victims were male young adults with low mortality. The TTSS and ISS were found to be adequate predictors of prolonged length of stay.
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Affiliation(s)
| | - Kelser de Souza Kock
- University of Southern Santa Catarina (UNISUL), Medicine Course Tubarão, Santa Catarina, Brazil
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15
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Mica L, Niggli C, Bak P, Yaeli A, McClain M, Lawrie CM, Pape HC. Development of a Visual Analytics Tool for Polytrauma Patients: Proof of Concept for a New Assessment Tool Using a Multiple Layer Sankey Diagram in a Single-Center Database. World J Surg 2020; 44:764-772. [PMID: 31712843 DOI: 10.1007/s00268-019-05267-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Early physiological assessment of multiple injured patients is crucial for decision making and has relied on personal experience of trauma experts. We have developed a new visual analytics tool (Sankey diagram, Watson Trauma Health care tool) that includes known prognostic parameters for polytrauma patients to help guide assessment and treatment decisions for physicians involved in trauma care. METHODS A prospectively collected trauma database of a single level I trauma center (3655 patients) was used. INCLUSION CRITERIA age >16 years, an injury severity score (ISS) >16 and presence of a complete data set in the database. Data collected included admission values of patient age, injury scoring, shock classification, temperature, acid-base and hemostasis parameters. All of these parameters were collected daily as longitudinal parameters. Endpoints of the clinical course we considered were sepsis, SIRS and early in hospital mortality (<72 h). A proof of concept of the visualization was developed over a 2-year period in a cooperation between physicians and engineers. Statistically, the most predictive parameters were selected by binary logistic regression and ROC analysis. RESULTS A dynamic interactive multilayer Sankey diagram, based on cohort similarities, was developed in a collaboration between the University Hospital of Zurich, Department of Trauma and IBM, from August 2017 until January 2018. It is a modular tool and allows any user to add a new patient, or work with an existing case. The visualization used the data-driven documents (D3) interactive visualization library to create a responsive graphic. CONCLUSIONS This application summarizes the experience of 3655 polytrauma patients and might serve as a guide for clinical decisions and educative purposes, as well as new scientific questions for the polytrauma patient. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ladislav Mica
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| | - Cedric Niggli
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Peter Bak
- IBM Haifa University Campus, 3498825, Mount Carmel Haifa, Israel
| | - Avi Yaeli
- IBM Haifa University Campus, 3498825, Mount Carmel Haifa, Israel
| | - Margaret McClain
- Gettysburg College, Durham University, 281 Canterwood Ln, Wexford, PA, 15090, USA
| | - Charles M Lawrie
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
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16
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Bachoumas K, Levrat A, Le Thuaut A, Rouleau S, Groyer S, Dupont H, Rooze P, Eisenmann N, Trampont T, Bohé J, Rieu B, Chakarian JC, Godard A, Frederici L, Gélinotte S, Joret A, Roques P, Painvin B, Leroy C, Benedit M, Dopeux L, Soum E, Botoc V, Fartoukh M, Hausermann MH, Kamel T, Morin J, De Varax R, Plantefève G, Herbland A, Jabaudon M, Duburcq T, Simon C, Chabanne R, Schneider F, Ganster F, Bruel C, Laggoune AS, Bregeaud D, Souweine B, Reignier J, Lascarrou JB. Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements. Ann Intensive Care 2020; 10:116. [PMID: 32852675 PMCID: PMC7450151 DOI: 10.1186/s13613-020-00733-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/17/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Nonintubated chest trauma patients with fractured ribs admitted to the intensive care unit (ICU) are at risk for complications and may require invasive ventilation at some point. Effective pain control is essential. We assessed whether epidural analgesia (EA) in patients with fractured ribs who were not intubated at ICU admission decreased the need for invasive mechanical ventilation (IMV). We also looked for risk factors for IMV. STUDY DESIGN AND METHODS This retrospective, observational, multicenter study conducted in 40 ICUs in France included consecutive patients with three or more fractured ribs who were not intubated at admission between July 2013 and July 2015. RESULTS Of the 974 study patients, 788 were included in the analysis of intubation predictors. EA was used in 130 (16.5%) patients, and 65 (8.2%) patients required IMV. Factors independently associated with IMV were chronic respiratory disease (P = 0.008), worse SAPS II (P < 0.0001), flail chest (P = 0.02), worse Injury Severity Score (P = 0.0003), higher respiratory rate at admission (P = 0.02), alcohol withdrawal syndrome (P < 0.001), and noninvasive ventilation (P = 0.04). EA was not associated with decreases in IMV requirements, median numerical rating scale pain score, or intravenous morphine requirements from day 1 to day 7. CONCLUSIONS EA was not associated with a lower risk of IMV in chest trauma patients with at least 3 fractured ribs, moderate pain, and no intubation on admission. Further studies are needed to clarify the optimal pain control strategy in chest trauma patients admitted to the ICU, notably those with severe pain or high opioid requirements.
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Affiliation(s)
| | - Albrice Levrat
- Intensive Care Unit, Regional Hospital Center, Annecy, France
| | - Aurélie Le Thuaut
- Plateforme de la méthodologie et de la Biostatistique, Direction de la Recherche Clinique, CHU de Nantes, 44093, Nantes Cedex, France
| | | | - Samuel Groyer
- Intensive Care Unit, Hospital Center, Montauban, France
| | - Hervé Dupont
- Surgical Intensive Care Unit, University Hospital, Amiens, France
| | - Paul Rooze
- Surgical Intensive Care Unit, University Hospital, Nantes, France
| | | | | | | | - Benjamin Rieu
- Surgical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | | | - Aurélie Godard
- Intensive Care Unit, Regional Hospital Center, Saint-Brieuc, France
| | - Laura Frederici
- Intensive Care Unit, Regional Hospital Center, Sud Francilien, Corbeil-Essone, France
| | | | - Aurélie Joret
- Surgical Intensive Care Unit, University Hospital, Caen, France
| | - Pascale Roques
- Intensive Care Unit, Regional Hospital Center, Cherbourg, France
| | - Benoit Painvin
- Intensive Care Unit, Regional Hospital Center, Lorient, France
| | - Christophe Leroy
- Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Marcel Benedit
- Intensive Care Unit, Regional Hospital Center, Moulins, France
| | - Loic Dopeux
- Intensive Care Unit, Regional Hospital Center, Vichy, France
| | - Edouard Soum
- Intensive Care Unit, Regional Hospital Center, Périgueux, France
| | - Vlad Botoc
- Intensive Care Unit, Regional Hospital Center, Saint-Malo, France
| | - Muriel Fartoukh
- Intensive Care Unit, University Hospital, Tenon, Paris, France
| | | | - Toufik Kamel
- Intensive Care Unit, Regional Hospital Center, Orléans, France
| | - Jean Morin
- Respiratory Care Unit, University Hospital, Nantes, France
| | - Roland De Varax
- Intensive Care Unit, Regional Hospital Center, Macon, France
| | | | | | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand and GReD, CNRS, UMR 6293, INSERM U1103, Universite Clermont Auvergne, Clermont-Ferrand, France
| | | | - Christelle Simon
- Intensive Care Unit, Regional Hospital Center, Versailles, France
| | - Russell Chabanne
- Neurological Intensive Care Unit, University Hospital, Clermont-Ferrand, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Cedric Bruel
- Intensive Care Unit, Saint-Joseph Hospital Center, Paris, France
| | | | | | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Jean Reignier
- Médecine Intensive Réanimation, University Hospital, Nantes, France
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Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients. J Clin Med 2020; 9:jcm9092752. [PMID: 32858822 PMCID: PMC7564760 DOI: 10.3390/jcm9092752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 01/08/2023] Open
Abstract
The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36–68), the overall Injury Severity Score (ISS) was 24 points (IQR 17–29), and a median BMI of 25.1 points (IQR 23–28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued.
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Demographic, Clinical Features and Outcome Determinants of Thoracic Trauma in Sri Lanka: A Multicentre Prospective Cohort Study. Can Respir J 2020; 2020:1219439. [PMID: 32655722 PMCID: PMC7322612 DOI: 10.1155/2020/1219439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/16/2020] [Indexed: 11/17/2022] Open
Abstract
Prognostic determinants in thoracic trauma are of major public health interest. We intended to describe patterns of thoracic trauma, demographic factors, clinical course, and predictors of outcome in selected tertiary care hospitals in Sri Lanka. A multicentre prospective cohort study was conducted in five leading teaching hospitals from June to September 2017. Patients with thoracic trauma were followed up during the hospital stay. A logistic regression analysis was conducted using in-hospital morbidity as the dichotomous outcome variable. One hundred seventy-one patients were included in the study yielding 1450 (median = 8.5) person-days of observation. Of them, 71.9% (n = 123) were males. The mean age was 45.8 ± 17.9 years. Majority (39.2%, n = 67) were recruited from the National Hospital of Sri Lanka. Automobile accidents were the commonest (62.6%, n = 107), followed by falls (26.9%, n = 46), assaults (8.8%, n = 15), and animal attacks (1.8%, n = 3). The ratio of blunt to penetrating trauma was 5.6 : 1. Injury patterns were rib fractures (80.7%, n = 138), haemothorax (44.4%, n = 76), pneumothorax (44.4%, n = 76), lung contusion (22.8%, n = 39), flail segment (15.8%, n = 27), tracheobronchial trauma (7.0%, n = 12), diaphragmatic injury (2.3%, n = 4), vascular injury (2.3%, n = 4), cardiac contusions (1.1%, n = 2), and oesophageal injury (0.6%, n = 1). Ninety nine (57.9%) had extrathoracic injuries. Majority (63.2%, n = 108) underwent operative management including intercostal tube insertion (60.8%, n = 104), wound exploration (6.4%, n = 11), thoracotomy (4.1%, n = 7), rib reconstruction (4.1%, n = 7), and video-assisted thoracoscopic surgery (2.9%, n = 5). Pneumonia (10.5%, n = 8), bronchopleural fistulae (2.3%, n = 4), tracheaoesophageal fistulae (1.8%, n = 3), empyema (1.2%, n = 2), and myocardial infarction (1.2%, n = 2) were the commonest postoperative complications. The mean hospital stay was 15.6 ± 18.0 days. The in-hospital mortality was 11 (6.4%). The binary logistic regression analysis with five predictors (age, gender, mechanism of injury (automobile/fall/assault), type of trauma (blunt/penetrating), and the presence of extrathoracic injuries) was statistically significant to predict in-hospital morbidity (X 2 (6, n = 168) = 13.1; p=0.041), explaining between 7.5% (Cox and Snell R 2) and 14.5% (Nagelkerke R 2) of variance. The automobile accidents (OR: 2.3, 95% CI = 0.2-26.2) and being males (OR: 2.3, 95% CI = 0.6-9.0) were the strongest predictors of morbidity.
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
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.
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Ong D, Cheung M, Cuenca P, Schauer S. Clinical Utility of Routine Chest X-Rays During the Initial Stabilization of Trauma Patients. South Med J 2019; 112:55-59. [PMID: 30608635 DOI: 10.14423/smj.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Advanced Trauma Life Support (ATLS) course encourages the use of chest x-ray (CXR) to identify injuries that may change clinical management during the initial stage of trauma resuscitations. Several studies have failed to show benefit for the routine use of CXR without a clinical indication, however. We sought to validate these findings by determining the incidence of clinically significant findings discovered on a portable single-view CXR during the initial stabilization of trauma patients at a Level 1 trauma center. METHODS Using our electronic medical record system, we searched for all of the patients who were brought in as a trauma activation that had a portable single-view CXR performed in the emergency department. We used a selected sampling of available subjects for inclusion into the study. We reviewed the staff radiologist reports for positive findings and reviewed the physician and nursing flow sheets for procedural interventions occurring after the CXR was performed but before leaving the resuscitation area. Subjects who were transferred from another facility, had a thoracic procedure performed before CXR or underwent computed tomography before CXRs were excluded. RESULTS From 2011 through 2012, we found 2101 subjects who had a portable CXR performed in the emergency department. We reviewed the first 400 subjects' records, with 33 (8.3%) subjects having positive findings on CXR. Of those 33, 8 met inclusion criteria and the remainder met exclusion criteria. The most common findings were pneumothorax (n = 4), clavicle fracture (n = 3), and rib fracture (n = 2). No subjects received a procedural intervention before leaving the resuscitation bay to be transported to the operating room or the computed tomography suite. CONCLUSIONS We observed a low incidence of abnormal findings on portable CXR during the initial stabilization of trauma patients, none of whom received an immediate procedural intervention. This dataset supports previously published reports that suggest that a more targeted approach to CXR use may reduce resource utilization.
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Affiliation(s)
- David Ong
- From the San Antonio Military Medical Center, Fort Sam Houston, the William Beaumont Army Medical Center, Fort Bliss, the Army Medical Department (AMEDD) Center and School, Fort Sam Houston, and the US Army Institute for Surgical Research, San Antonio, Texas
| | - Michael Cheung
- From the San Antonio Military Medical Center, Fort Sam Houston, the William Beaumont Army Medical Center, Fort Bliss, the Army Medical Department (AMEDD) Center and School, Fort Sam Houston, and the US Army Institute for Surgical Research, San Antonio, Texas
| | - Peter Cuenca
- From the San Antonio Military Medical Center, Fort Sam Houston, the William Beaumont Army Medical Center, Fort Bliss, the Army Medical Department (AMEDD) Center and School, Fort Sam Houston, and the US Army Institute for Surgical Research, San Antonio, Texas
| | - Steven Schauer
- From the San Antonio Military Medical Center, Fort Sam Houston, the William Beaumont Army Medical Center, Fort Bliss, the Army Medical Department (AMEDD) Center and School, Fort Sam Houston, and the US Army Institute for Surgical Research, San Antonio, Texas
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Lang NW, Schwihla I, Weihs V, Kasparek M, Joestl J, Hajdu S, Sarahrudi K. Survival rate and Outcome of extracorporeal life support (ECLS) for treatment of acute cardiorespiratory failure in trauma patients. Sci Rep 2019; 9:12902. [PMID: 31501453 PMCID: PMC6733857 DOI: 10.1038/s41598-019-49346-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/08/2019] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal life support (ECLS) remains the last option for cardiorespiratory stabilization of severe traumatic injured patients. Currently limited data are available and therefore, the current study assessed the survival rate and outcome of ECLS in a Level I trauma center. Between 2002 and 2016, 18 patients (7 females, 11 males) with an median age of 29.5 IQR 23.5 (range 1–64) years were treated with ECLS due to acute traumatic cardiorespiratory failure. Trauma mechanism, survival rate, ISS, SOFA, GCS, GOS, CPC, time to ECLS, hospital- and ICU stay, surgical interventions, complications and infections were retrospectively assessed. Veno-arterial ECLS was applied in 15 cases (83.3%) and veno-venous ECLS in 3 cases (16.6%). Survivors were significant younger than non-survivors (p = 0.0289) and had a lower ISS (23.5 (IQR 22.75) vs 38.5 (IQR 16.5), p = n.s.). The median time to ECLS cannulation was 2 (IQR 0,25) hours in survivors 2 (IQR 4) in non-survivors. Average GCS was 3 (IQR 9.25) at admission. Six patients (33.3%) survived and had a satisfying neurological outcome with a mean GOS of 5 (IQR 0.25) (p = n.s.). ECLS is a valuable treatment in severe injured patients with traumatic cardiorespiratory failure and improves survival with good neurological outcome. Younger patients and patients with a lower ISS are associated with a higher survival rate. Consideration of earlier cannulation in traumatic cardiorespiratory failure might be beneficial to improve survival.
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Affiliation(s)
- Nikolaus W Lang
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
| | - Ines Schwihla
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Valerie Weihs
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Maximilian Kasparek
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Julian Joestl
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Kambiz Sarahrudi
- Department of Orthopaedics & Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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Ayagara AR, Langlet A, Hambli R. On dynamic behavior of bone: Experimental and numerical study of porcine ribs subjected to impact loads in dynamic three-point bending tests. J Mech Behav Biomed Mater 2019; 98:336-347. [PMID: 31302583 DOI: 10.1016/j.jmbbm.2019.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 05/02/2019] [Accepted: 05/19/2019] [Indexed: 11/26/2022]
Abstract
This study covers the characterization of the dynamic behavior of isolated porcine ribs based on experimental and numerical approaches. A Split Hopkinson Pressure Bar (SHPB) setup for three-point bending tests was used. Data of 20 tests were considered to be comprehensible for experimental characterization, thereby, showing an influence of strain rate on both time for fracture and amplitudes of force response. A three-dimensional porcine rib model was generated from the DICOM (Digital Imaging and Communication in Medicine) images of High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT) scans. Material properties having been fitted by power law regression equations based on apparent density were assigned to the numerical rib. A modified elastic-plastic constitutive law, capable of considering the effects of strain rate was adopted. An incremental and stress-state dependent damage law, capable of considering effects of strain rate on fracture propagation, non-linear damage accumulation and instabilities was coupled to the constitutive law. The Finite Element (FE) model shows high efficiency in predicting both force-displacement curve and the fracture patterns of tested ribs. Predictions prove the ability of the proposed model to investigate the fracture behavior of human ribs under dynamic loads.
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Affiliation(s)
- Aravind Rajan Ayagara
- Laboratoire Gabriel Lamé, Univ. Orléans/Univ, Tours/INSA CVL, 63-Av de Lattre de Tassigny, 18020, Bourges, France
| | - André Langlet
- Laboratoire Gabriel Lamé, Univ. Orléans/Univ, Tours/INSA CVL, 63-Av de Lattre de Tassigny, 18020, Bourges, France.
| | - Ridha Hambli
- Laboratoire Gabriel Lamé, Univ. Orléans/Univ, Tours/INSA CVL, 63-Av de Lattre de Tassigny, 18020, Bourges, France
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van Rein EAJ, Lokerman RD, van der Sluijs R, Hjortnaes J, Lichtveld RA, Leenen LPH, van Heijl M. Identification of thoracic injuries by emergency medical services providers among trauma patients. Injury 2019; 50:1036-1041. [PMID: 30554896 DOI: 10.1016/j.injury.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/15/2018] [Accepted: 12/03/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Severe thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury. METHODS In this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3). RESULTS In total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers' judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider. CONCLUSION EMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.
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Affiliation(s)
- Eveline A J van Rein
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Robin D Lokerman
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rogier van der Sluijs
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rob A Lichtveld
- Regional Ambulance Facilities Utrecht, Bilthoven, the Netherlands.
| | - Luke P H Leenen
- Department of Traumatology, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Mark van Heijl
- Department of Traumatology, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, the Netherlands.
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Ferrah N, Cameron P, Gabbe B, Fitzgerald M, Judson R, Marasco S, Kowalski T, Beck B. Ageing population has changed the nature of major thoracic injury. Emerg Med J 2019; 36:340-345. [DOI: 10.1136/emermed-2018-207943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 12/18/2022]
Abstract
IntroductionAn increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system.MethodsThis was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period.ResultsThere were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18).ConclusionsAdmissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.
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To the Editor. J Orthop Trauma 2018; 32:e242-e244. [PMID: 29762433 DOI: 10.1097/bot.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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