Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience

Pulmonary Evaluation of Earthquake Victims Followed Up in the Intensive Care Unit After the 2023 Turkey Kahramanmaras Earthquakes

INTRODUCTION AND STUDY OBJECTIVE

In Turkey, a total of 269 earthquakes took place from 1900 through 2023. The most devastating earthquakes in terms of casualties and extensive destruction occurred at 4:17am and 1:24pm local time on February 6, 2023 with the epicenters located in Pazarcik (Kahramanmaras) and Ekinozu (Kahramanmaras) and magnitudes of 7.7Mw and 7.6Mw, respectively. The aim of this study was to define the frequency of lung complications that occurred directly and/or developed during the intensive care follow-up of individuals affected by the Kahramanmaras earthquakes.

METHOD

A retrospective evaluation was conducted on the files of 69 patients who were rescued from the debris of collapsed buildings after the Kahramanmaras earthquakes and followed up in the intensive care unit in terms of the time under the debris, demographic data, vital signs, and lung complications that were present at the time of admission and developed during follow-up. SPSS for Windows v. 20.0 was used for data analysis.

RESULTS

The study included a total of 69 patients, of whom 29 (42%) were female and 40 (58%) were male. The mean age was 39.9 (SD = 16.9) years. The mean time under the debris was 53.9 (SD = 52) hours, and the mean time from rescue to the intensive care unit admission was 18.7 (SD = 12.8) hours. One or more pulmonary complications were detected in 52.2% (n = 36) of the patients at the time of admission. During the follow-up, 30.4% (n = 21) of the patients developed pulmonary congestion, 13.0% (n = 9) pneumonia, 1.5% (n = 1) alveolar hemorrhage, and 1.5% (n = 1) atelectasis, while no additional lung complications developed in the remaining 37 patients (53.6%).

CONCLUSION

Severe cases of individuals recovered from the debris can have a high prevalence of earthquake-related lung disorders and chest trauma, which may be associated with high mortality. The timely identification and effective intervention of pulmonary complications that may develop during follow-up can reduce mortality.

Capsular pneumatosis: A rare radiographic sign for internal breast implant capsule violation in trauma

Breast augmentation is considered one of the most commonly performed procedures by aesthetic plastic surgeons, representing 16 % of all global plastic surgery procedures in 2020. Given the fact that thoracic trauma comprises over 20 % of trauma worldwide, it is unsurprising that there is potential for overlap between these two patient populations. Here, we present the case of a 59-year-old patient who had undergone bilateral breast augmentation over 10 years prior to presentation. They arrived as a highest-level trauma activation after being a helmeted cyclist struck by a motor vehicle resulting in significant left-sided thoracic trauma. Following stabilization in the trauma bay, CT imaging of the thorax demonstrated multifocal left pulmonary contusions and lacerations, multiple left-sided rib fractures (ribs 2-12), a small left pneumothorax, and left-sided subcutaneous emphysema. Imaging also demonstrated the presence of bilateral breast implants with the left implant appearing irregular in shape with the retropectoral space corresponding to the implant capsule having evidence of significant free air (capsular pneumatosis) concerning for acute traumatic rupture of the capsule. While undergoing surgical stabilization of her left-sided rib fractures, one of her ribs was noted to have violated the posterior wall of the breast capsule. Upon implant removal, the implant was found to have ruptured with tears in the shell corresponding to patient's rib fractures. This case represents a rare and unexpected complication of traumatic rib fractures; mainly the traumatic rupture of a silicone breast implant, which was identified by the presence of capsular pneumatosis on CT imaging. Presence of this rare radiographic sign (capsular pneumatosis) in the setting of a patient who has undergone breast augmentation should raise concern for possible implant rupture and capsule violation, even in the absence of external signs of penetrating injury.

Role of extracorporeal life support for traumatic hemopericardium: A single level I trauma center review

BACKGROUND

Traumatic hemopericardium may lead to cardiac tamponade, arrhythmia, arrest, or death and requires emergency surgery. We reviewed cases of traumatic hemopericardium in our center and the role of extracorporeal life support in these cases.

METHODS

From November 2011 to January 2022, 28 patients with significant hemopericardium and suspected cardiac injury were enrolled. In our center, surgery is the primary treatment of choice; however, if the patient is in an unstable condition, extracorporeal life support is administered in the emergency room prior to surgery.

RESULTS

Preoperative extracorporeal life support was applied to 10 patients (36 %). Two patients (20 %) were converted from extracorporeal life support to cardiopulmonary bypass during operation. After surgery, 2 patients (20 %) needed postoperative extracorporeal membrane oxygenation support. Overall, 21 patients (75 %) survived; of these, 6 (29 %) received extracorporeal life support. Meanwhile, 7 patients (25 %) died; of these, 4 patients (57 %) received extracorporeal life support.

CONCLUSION

Resuscitation method is the most crucial survival strategy in patients with severe chest trauma. Extracorporeal life support in cases of traumatic hemopericardium may be beneficial and efficient in stabilizing patients prior to surgery.

Comparing Sensitivity and Specificity of Ultrasonography With Chest Radiography in Detecting Pneumothorax and Hemothorax in Chest Trauma Patients: A Cross-Sectional Diagnostic Study

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.

Occult Pneumothorax in Blunt Thoracic Trauma: Clinical Characteristics and Results of Delayed Tube Thoracostomy in a Level 1 Trauma Center

Occult pneumothorax in blunt trauma patients is often diagnosed only after computed tomography because supine chest X-ray (CXR) is preferred as an initial evaluation. However, improperly managed preexisting occult pneumothorax could threaten the vitality of patients. Therefore, this study aimed to evaluate the incidence, characteristics, risk factors, and outcomes of occult pneumothorax in a single trauma center. From 2020 to 2022, patients who were admitted to the level 1 trauma center were retrospectively investigated. Inclusion criteria focused on blunt chest trauma. Variables including demographic factors, image findings, injury-related factors, tube thoracostomy timing, and treatment results were evaluated. Of the 1621 patients, 187 who met the criteria were enrolled in the study: 32 with overt pneumothorax and 81 with occult pneumothorax. Among all of the pneumothorax cases, the proportion of occult pneumothorax was 71.7% (81/113), and its incidence in all admitted trauma victims was 5.0% (81/1621). Subcutaneous emphysema and rib fractures on supine CXR were risk factors for occult pneumothorax. Six patients underwent delayed tube thoracostomy; however, none had serious complications. Given that occult pneumothorax is common in patients with blunt chest trauma, treatment plans should be established that consider the possibility of pneumothorax. However, the prognosis is generally good, and follow-up is an alternative.

Experience of Health Professionals in Caring for Patients With Chest Trauma: A Qualitative Study

BACKGROUND

The variation in the implementation of chest trauma (CT) management's guidelines led to inconsistent and mixed experiences toward CT management by the health care team. Moreover, there is a scarcity of studies exploring factors that enhance CT management experiences worldwide and in Jordan.

OBJECTIVES

The aims of this study were (1) to explore emergency health professionals' attitudes and experiences toward CT management and (2) to understand factors that affect the care for patients with CTs among emergency health professionals.

METHODS

A qualitative exploratory approach was adopted in this study. Individual, semistructured, face-to-face interviews were conducted with 30 emergency health professionals (physicians, nurses, and paramedics) from government emergency departments, military, private hospitals, and paramedics from the Civil Defense in Jordan.

RESULTS

The results showed that emergency health professionals had negative attitudes toward caring for patients with CTs due to a lack of knowledge and clarity in their job description and duties assigned to them. Moreover, some organizational and training factors were discussed for their impact on the attitudes of emergency health professionals toward caring for patients with CTs.

CONCLUSIONS

Lack of knowledge, absence of clear guidelines and job descriptions for dealing with traumas, and lack of continuous training on caring for patients with CTs were the most common reasons for negative attitudes. These findings can assist stakeholders, managers, and organizational leaders in understanding health care challenges and provoke a more focused strategic plan to diagnose and treat patients with CT.

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax

OBJECTIVE

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

METHODS

We conducted a retrospective institutional review board-approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

RESULTS

A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58-97), specificity of 100% (95% CI 99-100), positive predictive value of 81% (95% CI 54%-95%), and negative predictive value of 100% (95% CI 99%-100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%-78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

CONCLUSIONS

Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.

Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review

Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.

A retrospective validation study of the STUMBL score for emergency department patients with blunt thoracic trauma

INTRODUCTION

Blunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. Risk prediction tools are commonly to predict patients' outcomes and assign them to the most appropriate care setting. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; items comprising the score are age, number of rib fractures, use of pre-injury anticoagulants, chronic lung disease and oxygen saturation levels. This study's aim was to validate the STUMBL score in an Italian ED.

METHODS

This single-centre retrospective validation study was conducted in the ED of Santa Croce and Carle hub hospital in Cuneo, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were an age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow test and with the calibration belt.

RESULTS

745 patients were enroled (median age 64 [25th;75th percentile: 50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p < 0.001). The C index of the score for the primary outcome was 0.90 (95% CI 0.88-0.93), and the result of the Hosmer-Lemeshow test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity of 0.80 (95% CI 0.75-0.85), specificity of 0.87 (95% CI 0.84-0.90), a positive predictive value of 0.70 (95% CI 0.64-0.76), and a negative predictive value of 0.92 (95% CI 0.90-0.94).

CONCLUSION

In this validation study, the STUMBL score demonstrated excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality

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.

No role of antibiotics in patients with chest trauma requiring inter-costal drain: a pilot randomized controlled trial

PURPOSE

To study the role of prolonged prophylactic antibiotic therapy (PAT) in the prevention of Inter-costal drain (ICD) related infectious complications in patients with Blunt Trauma Chest (BTC).

METHODS

Patients of age 15 years and above with BTC requiring ICD were included. Patients with penetrating chest injuries, associated injuries/illnesses requiring antibiotic administration, need for mechanical ventilation, known pulmonary disease or immuno-compromised status and need for open thoracotomy were excluded. 120 patients were randomized equally to two groups; no prolonged PAT group (Group A) and prolonged PAT group (group B). Both group patients received one shot of injectable antibiotic prior to ICD insertion. Primary outcome measure was comparison of ICD related infectious complications (pneumonia, empyema and SSI) and secondary outcome measures included the duration of ICD, Length of Hospital stay (LOS) and in-hospital mortality in both the groups.

RESULTS

Infectious complications (pneumonia, empyema and SSI) were seen in only one patient in antibiotic group, and none in no antibiotic group (p value = 0.500). Other complications such as post ICD pain scores, respiratory failure requiring ventilatory support, retained hemothorax or recurrent pneumothorax, did not show any statistical difference between both groups. Also, no significant difference was seen in both the groups in terms of mean duration of ICD (p value = 0.600) and LOS (p value = 0.259).m CONCLUSION: Overall prevalence of ICD related infectious complications are low in BTC patients. Definitive role of prolonged prophylactic antibiotics in reducing infectious complications and other associated co morbidities in BTC patients with ICDs could not be established.

TRIAL REGISTRY DETAILS

Clinical Trial Registry, India (Trial registered at ctri.nic.in/clinical trials/login.php, number REF/2019/021704 dated 18/10/2019).

Delayed traumatic purulent pericarditis with cardiac tamponade - A rare case report

Thoracic trauma often results in immediate or delayed hemorrhage. There are few cases of purulent pericarditis with pericardial tamponade reported in the literature. If a devastating complication develops several weeks following blunt thoracic trauma, the causal relationship with the thoracic trauma event is less evident. As such, accurate diagnosis and subsequent effective treatment implementation is likely to be delayed. Herein, we present the case of a 46-year-old male patient with delayed purulent pericarditis that led to cardiac tamponade 2 weeks after the initial trauma.

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Cases of delayed traumatic purulent pericarditis with cardiac tamponade are rare.

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Here, delayed purulent pericarditis led to cardiac tamponade 2 weeks after trauma.

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This can occur without symptoms initially in chest trauma patients.

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Shortness of breath, pleural effusion, and cardiomegaly are signs and symptoms.

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This patient survived despite the 40 % mortality rate even with early diagnosis.

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone

The STUMBL (STUdy of the Management of BLunt chest wall trauma) score is a new prognostic score to assist ED (Emergency Department) decision making in the management of blunt chest trauma. This is a retrospective cohort chart review study conducted in a UK University Hospital ED seeing 120,000 patients a year, comparing its performance characteristics to ED clinician judgement. All blunt chest trauma patients that presented to our ED over a 6-month period were included. Patients were excluded if age < 18, if they had immediate life-threatening injury, required critical care admission for other injuries or in case of missing identification data. Primary endpoint was complication defined as any of lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. Clinician judgement (clinician decision to admit) and STUMBL score were compared using the receiver-operating curve (ROC) and sensitivity analysis. Three hundred and sixty-nine patients were included. ED clinicians admitted 95 of 369 patients. ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9% for the same and would have led to 117 of 369 patients being admitted. Area under the curve (AUC) of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78-0.90) and 0.85 (95% CI 0.79-0.91), respectively. Our findings show that a STUMBL score ≥ 11 performs no better than ED clinician judgement and leads to more patients being admitted to hospital.

Predictors of pleural complications in trauma patients undergoing tube thoracostomy: A prospective observational study

OBJECTIVE

to identify variables related to pleural complications in patients undergoing tube thoracostomies due to traumatic injuries.

METHOD

we conducted a prospective observational study from May/2019 to January/2021 including adult trauma patients submitted to tube thoracostomies after hospital admission. Patients undergoing thoracotomies as the initial treatment were not included. We excluded patients with suspected and confirmed COVID-19 diagnosis during the hospitalization. Pleural complications were defined as clotted hemothorax, residual pneumothorax and empyema. Students t, Mann Whitneys, Chi square and Fishers exact test were used to compare variables between groups. We considered p<0.05 as significant.

RESULTS

we analyzed 68 patients. The mean age was 36.0 + 12.6 years and 91.2% were male. The mean RTS and ISS were, respectively, 7.0 ± 1.6 and 15.9 ± 7.6. The most frequent trauma mechanism was stab wounds in 50.0%, followed by blunt trauma in 38.2%. The severity of thoracic injuries was stratified (AIS) as 2 (4.4%), 3 (80.9%), 4 (13.2%), e 5 (1.5%). Pleural complications happened in 14 (20.5%) patients, being clotted / residual hemothorax (11.8%), residual pneumothorax (4.4%), empyema (2.9%) and miscellaneous (1.4%). These patients were treated by thoracoscopy (5), thoracotomy (3), chest re-drainage (3) and clinical measures alone (3). There was a significant association between pleural complications with the time of permanence (p<0,001) and the necessity of relocation (p<0,001) of the drain.

CONCLUSION

the predictors of pleural complications in this series were time of permanence and the necessity of relocation of the drain.

Chest Trauma Management in Low- and Middle-Income Countries

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Fatores preditivos de complicações pleurais em vítimas de trauma submetidas à drenagem pleural: Estudo prospectivo observacional

RESUMO Objetivo: identificar as variáveis relacionadas às complicações pleurais em vítimas de trauma submetidas a drenagem torácica. Método: estudo observacional prospectivo entre maio/2019 e janeiro/2021, incluindo adultos submetidos a drenagem torácica após a admissão hospitalar para tratamento de lesões traumáticas. Pacientes que desenvolveram COVID19 foram excluídos. As complicações pleurais foram caracterizadas como: pneumotórax residual, hemotórax residual / coagulado e empiema pleural. Comparamos as variáveis coletadas entre os grupos de pacientes com e sem estas complicações. Os testes t de Student, Mann Whitney, Chi quadrado e Fisher foram utilizados para análise estatística. Foram considerados significativos valores de p<0,05. Resultados: analisamos 68 casos, com média etária de 36,0 + 12,6 anos, de RTS de 7,0 ± 1,6 e ISS de 15,9 ± 7,6, sendo 62 (91,2%) do sexo masculino. Trinta e quatro pacientes (50,0%) foram vítimas de ferimento por arma branca. O AIS das lesões torácicas foi classificado como 2 (4,4%), 3 (80,9%), 4 (13,2%), e 5 (1,5%). As complicações pleurais ocorreram em 14 casos (20,5%), sendo hemotórax residual / coagulado em 8 casos (11,8%), pneumotórax residual em 3 (4,4%), o empiema pleural em 2 (2,9%) e associações em 1 (1,4%). Estas complicações foram tratadas por videotoracoscopia (5 casos), toracotomia (3), redrenagem de tórax (3) e medidas clínicas apenas (3). A redrenagem de tórax (p<0,001) e o tempo de permanência do dreno (p<0,001) tiveram relação significativa com a presença de complicações pleurais. Conclusão: a redrenagem do tórax e o maior tempo de permanência do dreno foram associados às complicações pleurais.

[Is thoracoscopic heart suturing possible for stab wounds?]

The authors report two clinical cases with similar stab wounds of the heart. The first patient underwent open wound closure, the second one - thoracoscopic suturing of the wound. The authors concluded that conversion may be unnecessary after diagnosis of heart injury if severe bleeding is absent.

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.

Obesity Prolongs the Inflammatory Response in Mice After Severe Trauma and Attenuates the Splenic Response to the Inflammatory Reflex

Thoracic traumas with extra-thoracic injuries result in an immediate, complex host response. The immune response requires tight regulation and can be influenced by additional risk factors such as obesity, which is considered a state of chronic inflammation. Utilizing high-dimensional mass and regular flow cytometry, we define key signatures of obesity-related alterations of the immune system during the response to the trauma. In this context, we report a modification in important components of the splenic response to the inflammatory reflex in obese mice. Furthermore, during the response to trauma, obese mice exhibit a prolonged increase of neutrophils and an early accumulation of inflammation associated CCR2⁺CD62L⁺Ly6C^hi monocytes in the blood, contributing to a persistent inflammatory phase. Moreover, these mice exhibit differences in migration patterns of monocytes to the traumatized lung, resulting in decreased numbers of regenerative macrophages and an impaired M1/M2 switch in traumatized lungs. The findings presented in this study reveal an attenuation of the inflammatory reflex in obese mice, as well as a disturbance of the monocytic compartment contributing to a prolonged inflammation phase resulting in fewer phenotypically regenerative macrophages in the lung of obese mice.

Risk factors for ventilator-associated pneumonia in trauma patients with torso injury: a retrospective single-center study

Objective

We aimed to identify the risk factors for ventilator-associated pneumonia in patients admitted to critical care after a torso injury.

Methods

We retrospectively evaluated 178 patients with torso injury aged >15 years who were intubated in the emergency room and placed on a mechanical ventilator after intensive care unit (ICU) admission, survived for >48 hours, had thoracic and/or abdominal injuries, and had no end-stage renal disease. We compared clinico-laboratory variables between ventilator-associated pneumonia (n = 54, 30.3%) and non-ventilator-associated pneumonia (n = 124, 69.7%) groups. Risk factors for ventilator-associated pneumonia were assessed using multivariable logistic regression analysis.

Results

Ventilator-associated pneumonia was associated with a significantly longer stay in the ICU (11.3 vs. 6.8 days) and longer duration of mechanical ventilation (7 vs. 3 days). Injury Severity Score (adjusted odds ratio [AOR]: 1.048; 95% confidence interval [CI]: 1.008–1.090), use of vasopressors (AOR: 2.541; 95% CI: 1.121–5.758), and insertion of a nasogastric tube (AOR: 6.749; 95% CI: 2.397–18.999) were identified as independent risk factors of ventilator-associated pneumonia.

Conclusion

Ventilator-associated pneumonia in patients with torso injury who were admitted to the ICU was highly correlated with Injury Severity Score, use of vasopressors, and insertion of a nasogastric tube.

Prehospital paramedic pleural decompression: A systematic review

BACKGROUND

Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown.

AIM

To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics.

METHODS

We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25^th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians).

RESULTS

The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival.

CONCLUSION

Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.

Risk of Pneumonia in Pediatric Patients Following Minor Chest Trauma: A Population-Based Retrospective Cohort Study

This study investigated the association between minor chest trauma and the risk of pneumonia among pediatric patients in a Taiwanese health care setting. For this retrospective population-based cohort study, the Longitudinal Health Insurance Database was used to analyze the data of patients with a minor chest injury between 2010 and 2012. Data were analyzed through a multivariate analysis with a multiple Cox regression model. Patients were divided into a chest trauma group (n = 6592) and a non-chest trauma group (n = 882,623). An increased risk of pneumonia was observed in the chest trauma group (hazard ratio = 1.23; 95% confidence interval = 1.02–1.49) compared to the non-chest trauma group. In conclusion, this population-based cohort study demonstrated that pediatric patients with minor chest trauma are at an increased risk of pneumonia. The short-term adverse effects of pneumonia could be severe when a patient suffers from mild chest trauma.

Changes in extracellular cytokines in predicting disease severity and final clinical outcome of patients with blunt chest trauma

BACKGROUND

Chest trauma causes substantial morbidity and mortality and its severity is assessed using clinical diagnosis or scoring systems like Injury severity score (ISS) and thoracic trauma severity score (TTSS). Association of inflammatory cytokines with severity of disease and final clinical outcome is not clearly defined in patients with chest trauma. In this study, we thought to evaluate the inflammatory response in serum and bronchoalveolar lavage fluid (BALF) in chest trauma patients and correlate the level of extracellular cytokines with diseases severity and final outcome.

METHODS

A total of 65 patients with blunt chest trauma and 30 healthy controls were enrolled in this prospective observational study. Assessment of inflammatory cytokines such as Interleukin (s) - IL-5, IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F,IL-4, IL-21 and IL-22 was performed in both serum and bronchoalveolar lavage fluid using 13-plex multiplex kit using fluorescence-encoded bead based immunoassays.

RESULTS

A significantly higher level of IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F, IL-21 and IL-22 cytokines were observed in patients with blunt chest trauma compared to healthy controls. Level of IL-2, IL-6, IL-1β and IL-17A was significantly raised in the patients with blunt chest trauma who had a fatal outcome during the hospital stay. An elevated cytokine response of IL-13, IL-4, and IL-21 was noted in the group of patients with high (>5) thoracic trauma severity score.

CONCLUSION

Routine monitoring of the inflammatory cytokine level in patients with chest trauma may be used routinely. Longer prospective studies should be encouraged to determine the role of cytokines in patients with chest trauma in predicting the patient final clinical outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Chest Trauma Experience: Incidence, associated factors, and outcomes among patients in Saudi Arabia

Background and Objective:

Worldwide chest trauma is considered one of the leading causes of morbidity and mortality. There is a lack of sufficient information on the etiology, pattern, and management of these injuries in Saudi Arabia. Therefore, the current study was conducted to determine the spectrum of chest trauma and its associated factors among patients admitted to King Khalid University Hospital, Riyadh, Saudi Arabia.

Methods:

A quantitative observational cross-sectional analysis was performed, data obtained from the medical records of the chest trauma patients which were admitted in the thoracic surgery unit, King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia from January 2013 to Jan 2019. The records of all these patients were reviewed and data were collected and analyzed prospectively.

Results:

A total of 236 patients (male: 87.3%; mean age: 32.4 years) were included in the analyses. The majority of these chest trauma cases (n=205; 86.9%) were caused by road traffic accidents (RTA). Blunt trauma predominated the cases n=225 (95.3%). Ribs fracture had the highest prevalence among the chest injuries with a number of 150 (63.5%) followed by lung contusion 140 (59.3%). Pneumothorax occurred in 131 (55.5%) and hemothorax occurred in 80 (33.8%) with most common indication for emergency thoracotomy. Extra-thoracic injuries involving the head/brain, limbs, and abdominal organs occurred in 189 (80%). 130 (55%) were intubated and ventilated, and almost half of the patients 115 (48.7%) were required a chest tube insertion.

Conclusions:

Chest trauma is a major health issue particularly in young male adults and road traffic accidents are the leading cause of chest trauma in Saudi Arabia. Early recognition of the patterns, etiology and appropriate management of trauma reduce the incidence of chest trauma related injuries.

Incentive spirometry to prevent pulmonary complications after chest trauma: a retrospective observational study

Aim

Pulmonary complications (PCs) are a major cause of poor prognosis in chest trauma. Evidence on the effectiveness of incentive spirometry (IS) in trauma is scarce. This study investigated the effectiveness of IS in preventing PCs in patients with chest trauma with rib fractures.

Methods

This retrospective observational study analyzed the data obtained from the electronic medical records of patients with chest trauma with rib fractures admitted between 2011 and 2019. We included patients 18 years of age or older with risk of worsening respiratory failure. Early IS was the primary exposure and PCs (pulmonary infection or respiratory failure requiring escalating oxygen therapy) were the primary outcomes. Secondary outcomes were length of hospital stay, duration of oxygenation therapy, and adverse events of IS. Logistic regression analysis with a propensity score was used.

Results

We extracted 514 patients from the electronic medical records; 299 patients were included. The early IS group had a higher proportion of hypoxemia at admission, opioid analgesia use, invasive positive pressure ventilation, and respiratory physiotherapy. The severity of trauma was higher in the early IS group. There was no significant difference in the occurrence of the PCs between groups (adjusted odds ratio 0.71; 95% confidence interval, 0.24–2.16). No statistical differences were seen in the secondary outcomes.

Conclusion

For patients with chest trauma with rib fractures at risk of worsening respiratory failure, IS early after injury did not reduce the rate of PCs. No adverse event of IS was observed and IS was shown to be safe.

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

Abstract

Objectives

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

Patients and methods

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

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

Results

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

Conclusions

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

Blunt trauma related chest wall and pulmonary injuries: An overview

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

Investigation of histopathological and radiological effects of surfactant treatment in an experimental female rat model of lung contusion

Objective(s):

Pulmonary contusion (PC) is a clinical entity that often accompanies blunt traumas. We aimed to investigate the radiological and histopathological effects of surfactant treatment in an experimental rat model in which lung contusion was formed by blunt thoracic trauma.

Materials and Methods:

50 female Sprague-Dawley rats were used. Five groups were formed randomly. In groups 2, 4, and 5 lung contusion was made by the drop-weight method after anesthesia. Intratracheal surfactant was administered in the 4th hr in groups 3 and 4 and in the 24th hr in groups 4 and 5. All rats were sacrificed and their lungs removed at 48 hr after contusion. Alveolar edema, congestion, hemorrhage, destruction, leukocyte infiltration, immune staining were examined histopathologically.

Results:

When the first thoracic CT scans were evaluated, we observed two rats with rib fractures and four rats with pneumothorax. 4 and 48 hr thoracic CT evaluation contusion and atelectasis showed no statistically significant decrease (P>0.05). After sacrifice of group 2, in macroscopic evaluation, there was a heterogeneous contusion and hemorrhagic appearance in the lungs of rats and less hemorrhagic appearance was observed in Groups 4 and 5 than in Group 2. In comparison of Immunohistopathological findings, surfactant treatment showed a statistically significant decrease in leukocyte infiltration scores (P=0.046). Immunohistopathologically, surfactant group had more staining but only statistically significant when compared to groups 4 and sham. (P=0.036).

Conclusion:

Surfactant treatment may be of significant benefit in lung contusion secondary to blunt chest trauma, and further prospective evidence of its efficacy in such disorders is needed.

Hemothorax: A Review of the Literature

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.

Higher Mortality Rate in Moderate-to-Severe Thoracoabdominal Injury Patients with Admission Hyperglycemia Than Nondiabetic Normoglycemic Patients

Background: Hyperglycemia at admission is associated with an increase in worse outcomes in trauma patients. However, admission hyperglycemia is not only due to diabetic hyperglycemia (DH), but also stress-induced hyperglycemia (SIH). This study was designed to evaluate the mortality rates between adult moderate-to-severe thoracoabdominal injury patients with admission hyperglycemia as DH or SIH and in patients with nondiabetic normoglycemia (NDN) at a level 1 trauma center. Methods: Patients with a glucose level ≥200 mg/dL upon arrival at the hospital emergency department were diagnosed with admission hyperglycemia. Diabetes mellitus (DM) was diagnosed when patients had an admission glycohemoglobin A1c ≥6.5% or had a past history of DM. Admission hyperglycemia related to DH and SIH was diagnosed in patients with and without DM. Patients who had a thoracoabdominal Abbreviated Injury Scale score <3, a polytrauma, a burn injury and were below 20 years of age were excluded. A total of 52 patients with SIH, 79 patients with DH, and 621 patients with NDN were included from the registered trauma database between 1 January 2009, and 31 December 2018. To reduce the confounding effects of sex, age, comorbidities, and injury severity of patients in assessing the mortality rate, different 1:1 propensity score-matched patient populations were established to assess the impact of admission hyperglycemia (SIH or DH) vs. NDN, as well as SIH vs. DH, on the outcomes. Results: DH was significantly more frequent in older patients (61.4 ± 13.7 vs. 49.8 ± 17.2 years, p < 0.001) and in patients with higher incidences of preexisting hypertension (2.5% vs. 0.3%, p < 0.001) and congestive heart failure (3.8% vs. 1.9%, p = 0.014) than NDN. On the contrary, SIH had a higher injury severity score (median [Q1–Q3], 20 [15–22] vs. 13 [10–18], p < 0.001) than DH. In matched patient populations, patients with either SIH or DH had a significantly higher mortality rate than NDN patients (10.6% vs. 0.0%, p = 0.022, and 5.3% vs. 0.0%, p = 0.043, respectively). However, the mortality rate was insignificantly different between SIH and DH (11.4% vs. 8.6%, odds ratio, 1.4; 95% confidence interval, 0.29–6.66; p = 0.690). Conclusion: This study revealed that admission hyperglycemia in the patients with thoracoabdominal injuries had a higher mortality rate than NDN patients with or without adjusting the differences in patient’s age, sex, comorbidities, and injury severity.

Thoracic trauma: a descriptive review of 4168 consecutive cases in East China

Thoracic trauma in China was scarcely reported. This study aimed to summarize the clinical profiles and to analyze the management approaches of patients with traumatic thoracic injury.Data for consecutive patients with thoracic trauma from January 2003 to January 2018 were retrospectively collected and analyzed. Patients' profiles and clinical outcomes were compared between those patients treated with a dedicated thoracic trauma team and those without.The study included 4168 patients with mean age of 49.0 years, of whom 82.1% were male. Traffic accident accounted for 42.7% of the injuries. Most of the patients (66.8%) had rib fractures. Associated injuries were present in 48.3% of the patients; of them 86.0% were extremity fractures. Majority of the patients were managed without surgical procedures other than tube thoracostomy (33.2%). ICU service was needed in 12.0% of the patients. Patients treated with thoracic trauma team were older (53.59 ± 16.8 year vs 45.1 ± 18.0 year, P < .001), less male (78.3% vs 85.2%, P < .001), with higher injury severity scores (17.5 ± 10.1 vs 13.7 ± 8.2, P < .001), required more ventilator support (48.3% vs 25.3%, P < .001) and underwent more tube thoracostomy and other surgeries (43.8% vs 24.2%, and 34.4% vs 14.1%, respectively, all P < .001), yet with a shorter hospital stay (11.7 ± 9.0 days vs 12.7 ± 8.8 days, P < .001), and numerically lower ICU usage and mortality when compared to those without.Thoracic trauma in China usually affects mid-age males. Traffic accident is the top one etiology. The most common type of thoracic injuries is rib fracture. Associated injuries occur frequently. Nonoperative treatment and tube thoracostomy are effective for majority of the patients. A multidisciplinary approach with a dedicated thoracic trauma team could improve the treatment for these patients.

Chest drain and thoracotomy for chest trauma

Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.

Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study

BACKGROUND

Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard.

METHODS

A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated.

RESULTS

A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively.

CONCLUSION

Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.

Orem’s Self-Care Model With Trauma Patients: A Quasi-Experimental Study

To examine if the application of Orem’s self-care model could improve self-care knowledge, attitudes, practices, and respiratory conditions of trauma patients with chest tubes, a quasi-experimental study was conducted. The participants were assigned to two groups—namely, Orem’s model and routine care. Although the patients’ self-care knowledge, attitudes, and practices were improved in both groups over the course of 3 days since the initial assessments, there was a greater degree of improvement in the experimental group than that in the control group. However, there were no differences in the improvement of the chest parameters between the two groups. Orem’s model was effective in improving self-care in patients with chest tube.

An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20-25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity.

Risk Factors for Pneumonia in Ventilated Trauma Patients with Multiple Rib Fractures

Background

Ventilator-associated pneumonia (VAP) is a common disease that may contribute to morbidity and mortality among trauma patients in the intensive care unit (ICU). This study evaluated the associations between trauma factors and the development of VAP in ventilated patients with multiple rib fractures.

Methods

We retrospectively and consecutively evaluated 101 patients with multiple rib fractures who were ventilated and managed at our hospital between January 2010 and December 2015, analyzing the associations between VAP and trauma factors in these patients. Trauma factors included sternal fracture, flail chest, diaphragm injury, traumatic aortic dissection, combined cardiac injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, abbreviated injury scale score, thoracic trauma severity score, and injury severity score.

Results

Forty-six patients (45.5%) had at least 1 episode of VAP, 10 (21.7%) of whom died in the ICU. Of the 55 (54.5%) patients who did not have pneumonia, 9 (16.4%) died in the ICU. Using logistic regression analysis, we found that VAP was associated with severe lung contusion (odds ratio, 3.07; 95% confidence interval, 1.12 to 8.39; p=0.029).

Conclusion

Severe pulmonary contusion (pulmonary lung contusion score 6–12) is an independent risk factor for VAP in ventilated trauma patients with multiple rib fractures.

Radiologic findings of thoracic trauma

Introduction

Chest trauma may be blunt or penetrating and the chest is the third most common trauma region. It is a significant cause of mortality. Multidetector computed tomography (MDCT) has been an increasingly used method to evaluate chest trauma because of its high success in detecting tissue and organ injuries. Herein, we aimed to present MDCT findings in patients with blunt and penetrating chest trauma admitted to our department.

Methods

A total of 240 patients admitted to the emergency department of our hospital between April 2012 and July 2013 with a diagnosis of chest trauma who underwent MDCT evaluations were included. Most of the patients were male (83.3%) and victims of a blunt chest trauma. The images were analyzed with respect to the presence of fractures of bony structures, hemothorax, pneumothorax, mediastinal organ injury, and pulmonary and vascular injuries.

Results

MDCT images of the 240 patients yielded a prevalence of 41.7% rib fractures, 11.2% scapular fractures, and 7.5% clavicle fractures. The prevalence of thoracic vertebral fracture was 13.8% and that of sternal fracture was 3.8%. The prevalence of hemothorax, pneumothorax, pneumomediastinum, and subcutaneous emphysema was 34.6%, 62.1%, 9.6%, and 35.4%, respectively. The prevalence of rib, clavicle, and thoracic vertebral fractures and pulmonary contusion was higher in the blunt trauma group, whereas the prevalence of hemothorax, subcutaneous emphysema, diaphragmatic injury, and other vascular lacerations was significantly higher in the penetrating trauma group than in the blunt trauma group (p<0.05).

Conclusion

MDCT images may yield a high prevalence of fracture of bony structures, soft tissue lacerations, and vascular lesions, which should be well understood by radiologists dealing with trauma.

Studying Morbidity and Predicting Mortality in Patients with Blunt Chest Trauma using a Novel Clinical Score

BACKGROUND

A departmental audit in March 2015 revealed significant mortality rate of 40% in blunt chest trauma patients (much greater than the global 25%). A study was thus planned to study morbidity and predictors of mortality in blunt chest trauma patients admitted to our hospital.

METHODS

This study was a prospective observational study of 139 patients with a history of blunt chest trauma between June 2015 and November 2015 after the Institutional Ethics Committee approval in April 2015. The sample size was calculated from the prevalence rate in our institute from the past medical records.

RESULTS

The morbidity factors following blunt chest injuries apart from pain were need for Intensive Care Unit stay, mechanical ventilation, and pneumonia/acute respiratory distress syndrome. Significant predictors of mortality in our study were SpO2 <80 at the time of presentation, Glasgow coma scale ≤ 8, patients with four or more rib fractures, presence of associated head injury, Injury Severity Score >16, and need for mechanical ventilation. By calculating the likelihood ratios of each respiratory sign, a clinical score was devised.

CONCLUSION

The modifiable factors affecting morbidity and mortality were identified. Mild to moderate chest injury due to blunt trauma is difficult to diagnose. The restoration of respiratory physiology has not only significant implications on recovery from chest injury but also all other injuries. It is our sincere hope that the score we have formulated will help reduce mortality and morbidity after further trials.

Full Airway Drainage by Fiber Bronchoscopy Through Artificial Airway in the Treatment of Occult Traumatic Atelectasis

The objective of this study is to investigate the effects of full airway drainage by fiber bronchoscopy through artificial airway in the treatment of traumatic atelectasis with occult manifestations. From May 2006 to May 2011, 40 cases of occult traumatic atelectasis were enrolled into our prospective study. Group A (n = 18) received drainage by nasal bronchoscope; group B underwent airway drainage by fiber bronchoscopy through artificial airway (n = 22). The effects of treatment were evaluated by the incidence of adult respiratory distress syndrome (ARDS), lung abscess, and the average length of hospital stay. Compared with nasal fiber-optic treatment, airway drainage by fiber bronchoscopy through artificial airway reduced the incidence of ARDS (p = 0.013) and lung abscess (p = 0.062) and shortened the mean length of stay (p = 0.018). Making the decision to create an artificial airway timely and carry out lung lavage by fiber bronchoscopy through artificial airway played a significant role in the treatment of occult traumatic atelectasis.

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

Background:

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

Objectives:

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

Patients and Methods:

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

Results:

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

Conclusions:

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