Pulmonary fat embolism in non-survivors after cardiopulmonary resuscitation

BACKGROUND

Blunt trauma acting against the human body presents the fundamental cause of pulmonary fat embolism (PFE) and fat embolism syndrome. The aim of the present study was to investigate PFE in non-survivors after cardiopulmonary resuscitation (CPR).

METHODS

This was a prospective cohort study conducted in University Hospital Ostrava, Czech Republic. Within a 4-year study period, all non-survivors after CPR because of out-of-hospital cardiac arrest were assessed for the study eligibility. The presence/seriousness of PFE was determined by microscopic examination of cryo-sections of lung tissue (staining with Oil Red O).

RESULTS

In total, 106 persons after unsuccessful CPR were enrolled in the study. The most frequent cause of death in the study population (63.2% of cases) was cardiac disease (ischemic heart disease); PFE was not determined as the cause of death in any of our study cases. Sternal fractures were identified 66.9%, rib fractures (usually multiple) in 80.2% of study cases; the median number of rib fractures was 10.2 fractures per person. Serious intra-thoracic injuries were found in 34.9% of cases. Microscopic examination of lung cryo-sections revealed PFE in 40 (37.7%) study cases; PFE was most frequently evaluated as grade I or II. Occurrence of sternal and rib fractures was significantly higher in persons with PFE than between persons without PFE (p = 0.033 and p = <0.001). Number of rib fractures was also significantly higher in persons with PFE. The occurrence of serious intra-thoracic injuries was comparable in both our study groups (p = 0.089).

CONCLUSIONS

PFE presents a common resuscitation injury which can be found in more than 30% of persons after CPR. Persons with resuscitation skeletal chest fractures have significantly higher risk of PFE development. During autopsy of persons after unsuccessful CPR, it is necessary to distinguish CPR-associated injuries including PFE from injuries that arise from other mechanisms.

Rib and sternum fracture risks for restrained occupants in frontal car crashes

OBJECTIVE

Most car occupant fatalities occur in frontal crashes and the thorax is the most frequently injured body region. The objectives of the study were, firstly, to quantify the relation between risk factors (such as speed and occupant age) and rib and sternum fracture injury probability in frontal car crashes, and, secondly, to evaluate whether rib fracture occurrence can predict sternum fractures.

METHODS

Weighted German data from 1999-2021 were used to create the injury risk curves to predict both, at least moderate and at least serious, rib and sternum fracture risks. A contingency table for rib and sternum fractures allowed the calculation of sensitivity, specificity, and precision, as well as testing for the association.

RESULTS

Elderly occupants (≥65 years old) had increased rib and sternum fracture risk compared to mid aged occupants (18-64 years old). Besides occupant age, delta-V was always and sex sometimes a significant predictor for skeletal thoracic injury. Sternum fractures were more common than rib fractures and more likely to occur at any given delta-V. Sternum fractures occurred often in isolation. Female occupants were at higher risk than males to sustain at least moderate rib and sternum fractures together and sternum fractures in isolation. Rib and sternum fractures were associated, but low sensitivity and precision show that rib fractures do not predict sternum fractures well.

CONCLUSIONS

Elderly and female occupants were at the highest risk and should be targeted by thoracic injury criteria and thresholds for frontal crash occupant protection. Rib and sternum fractures were not associated. Therefore, sternum fractures need to be predicted and evaluated separately from rib fractures.

Breaking point? An analysis of fatal stab wounds to the torso in Ireland between 2011 and 2018, examining the extent of rib fractures

This study examines the pattern of rib injuries occurring in cases of fatal torso stab wounds in Ireland between 2011 and 2018. It has been suggested by previous studies that rib fractures are not commonly sustained in stab wounds to the torso. We wanted to ascertain whether this was the case, as our data suggested that rib fractures were frequent, and where a rib is fractured there is a higher chance of organ injury and death, making this an important area of study. One hundred and forty seven cases of fatal stab wounds from an eight-year period were retrospectively reviewed. Fatal stab wounds to other body areas, were excluded; leaving a total of 104 cases with stab wounds to the torso. We found that 69.2% of cases had rib injuries, a figure significantly higher than previously reported. Our data suggests that stab wounds to the torso often fracture ribs, putting the underlying organs at increased risk of injury and perhaps contributing to fatality. The amount of force needed to cause a rib fracture can be difficult to quantify and indeed from the high percentage of rib fractures sustained in our data it appears that the ribs may be fractured regardless of the amount of force used; this is borne out by the finding that self-inflicted injuries also caused rib fractures. Our study shows that other factors, such as anatomical positioning and wound depth may have a greater bearing than force in terms of whether a rib fracture is sustained.

Incidence and Risk Factors of Heterotopic Ossification in the Knee After Reamed Tibial Nailing

INTRODUCTION

Heterotopic ossification (HO) in the knee after tibial intramedullary nailing (IMN) has yet to be thoroughly investigated. Our aim was to assess frequency and associated factors for HO in the knee after tibial IMN.

METHODS

This is a retrospective review at a single level 1 urban trauma center of 213 patients who underwent reamed tibial IMN. Plain radiographs were reviewed postoperatively and on final follow-up (≥6 weeks). Chart review was performed for surgical approach (suprapatellar versus infrapatellar), demographics, injury characteristics, and clinical follow-up. The primary outcome was frequency of HO.

RESULTS

HO on final follow-up (mean: 41.43 weeks) was recorded in 15% cases. Postsurgical retroinfrapatellar reaming debris (odds ratio [OR], 4.73), Injury Severity Score (OR, 1.05), intensive care unit admission (OR, 2.89), chest injury (OR, 3.4), and ipsilateral retrograde femoral IMN (OR, 5.08) showed a notable association with HO development. No association was observed in HO formation between surgical approach, knee pain, or range-of-motion deficits.

DISCUSSION

Radiographic evidence of HO in the knee after reamed tibial IMN is not uncommon and is associated with retained reaming debris, Injury Severity Score, chest injury, intensive care unit admission, and ipsilateral retrograde femoral nailing. No differences were noted in HO formation between approaches. HO was not associated with knee pain or range-of-motion deficits.

Analysis of thoracic trauma patients transferred to Türkiye's largest hospital after Kahramanmaraş earthquake

BACKGROUND

On February 6, 2023, an earthquake in Türkiye caused massive destruction. Over 50.000 people are known to have lost their lives, and over 100.000 are known to have been maimed. In our study, we aimed to analyze the treatment process of 267 METHODS: The demographic characteristics, the time spent under the rubble, the duration of transfer to the hospital, and the treatment process of patients admitted to our hospital have been evaluated.

RESULTS

There are 125 (46.8%) men and 142 (53.2%) women in the study. The rate of thoracic trauma was 21.8%. Of all the patients, 15.7% (n=42) had pneumothorax, 18% (n=48) had contusion, 28.8% (n=77) had hemothorax, and 73% (n=195) had rib fractures. The mean time spent under the rubble was 17.6±26.5 h, the duration of transfer to the hospital was 138.5±113.6 h, and the hospitalization time was 93.8±152.3 h. The duration of hospitalization and transfer has been statistically longer for the patients who were under the rubble (85.4%) than for those who were not. (14.6%) (p=0.048). There is a statistically weak positive correlation between the time spent under the rubble and the time of transfer (p=0.048).

CONCLUSION

The state, the time spent under the rubble, and the presence of hemothorax and pneumothorax should be effectively evaluated in earthquake-induced thoracic traumas. Considering these criteria in the transfer of patients to the centers operating at full capacity in a short time will minimize morbidity and mortality.

Fractured sternal wire causing a cardiac laceration

BACKGROUND

Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-operative causes are due to inflammation and bleeding, patients with broken sternal wires and an unstable sternum may develop hemopericardium from penetrating trauma.

CASE PRESENTATION

We present the case of a 62-year-old male who underwent triple coronary bypass surgery and presented five months later with sudden anterior chest wall pain. Chest computed tomography revealed hemopericardium with an associated broken sternal wire that had penetrated into the pericardial space. The patient underwent a redo-sternotomy which revealed a 3.5 cm bleeding, jagged right ventricular laceration that correlated to the imaging findings of a fractured sternal wire projecting in the pericardial space. The laceration was repaired using interrupted 4 - 0 polypropylene sutures in horizontal mattress fashion between strips of bovine pericardium. The patient's recovery was uneventful and he was discharged on post-operative day four without complications.

CONCLUSION

Patients with broken sternal wires and an unstable sternum require careful evaluation and management as these may have potentially life-threatening complications if left untreated.

Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions

OBJECTIVE

This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database.

METHODS

This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group.

RESULTS

The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk.

CONCLUSIONS

The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

Esophageal rupture after Heimlich maneuver: a case report and literature review

The Heimlich maneuver (HM) is lifesaving in a patient choked by a foreign body. It is safe and effective and does not require specific instruments. Nevertheless, rare severe complications have been reported, such as traumatic injury of the gastrointestinal tract, pneumomediastinum, rib fracture, diaphragm rupture, acute thrombosis of abdominal aortic aneurysm and mesenteric laceration. Abdominal injuries are the most common complications, especially esophageal and gastric wall rupture. This anatomic site is the most common location of organ injuries, in consequence of the main target of the force generated by the HM. Furthermore, the execution of HM by an untrained person may increase the risk for possible serious complications. Usually, HM complications are treated surgically, but based on clinical conditions, a conservative approach is possible. In our report, we described a case of esophageal rupture after a forceful HM, and we made a brief revision of literature concerning HM complications. We have also assessed the correlation between HM complications, abuse of non-steroidal anti-inflammatory drugs and the execution of the abdominal thrusts by untrained rescuers.

Sex Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

OBJECTIVE

Current literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI.

METHODS

A retrospective cohort study was performed of all patients who underwent TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2016 and 2019. The primary outcome was in hospital death. Secondary outcomes were peri-operative complications. Multivariable logistic regression was used to adjust for demographics, comorbidities, injury severity score, and aortic injury grade.

RESULTS

Two thousand and twenty-two patients were included; 26% were female. Compared with males, females were older (46 [IQR 30, 62] vs. 39 [IQR 28, 56] years; p < .001), more often obese (41% vs. 33%; p = .005), had lower rates of alcohol use disorder (4.1% vs. 8.9%; p < .001) and a higher prevalence of hypertension (29% vs. 22%; p = .001). The injury severity was comparable between females and males (Injury Severity Score ≥ 25; 84% vs. 80%; p = .11) and there was no difference in aortic injury grades when comparing females with males (grade 1, 33% vs. 33%; grade 2, 24% vs. 25%; grade 3, 43% vs. 40%; grade 4, 0.8% vs. 1.3%; p = .53). Multivariable logistic regression demonstrated no difference for in hospital mortality between females and males (OR 1.02; 95% CI 0.67 - 1.53, p = .93). Compared with males, females were at lower risk of acute kidney injury (AKI) (OR 0.33; 95% CI 0.17 - 0.64; p = .001) and ventilator associated pneumonia (VAP) (OR 0.50; 95% CI 0.28 - 0.91; p = .023).

CONCLUSION

This study did not demonstrate a sex related in hospital mortality difference following TEVAR for BTAI. However, female sex was associated with a lower risk of AKI and VAP. Future studies should evaluate sex differences and long term outcomes following TEVAR in patients with BTAI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Forensic characteristics of injuries in cyclists in collisions with other vehicles]

In order to identify the features of the injuries formation in cyclists who were injured in a collision of moving vehicles with a blow to the rear wheel area of a bicycle moving at a slower speed in the same direction, the authors analyzed the results of forensic medical examinations in relation to 151 corpses of cyclists who died in road accidents aged 4 to 74 years. It was found that with this type of bicycle injury, the structures of the head, chest, lower extremities, as well as the structures of the abdomen were most often injured. Injuries to the structure of the head were characterized by the formation of depressed-comminuted fractures: more often frontal-temporal, less often occipital bone. Bilateral fractures of the ribs were also quite frequent types of damage, mainly the upper ribs (up to 5-6 ribs) were damaged, most often along the midclavicular and anterior axillary lines. Lung contusions have been identified in most of the injured persons with chest structure injury. Injuries to the abdominal organs and retroperitoneal space were recorded in 22.27% of cases, with liver and spleen ruptures in the majority of cases. Spinal injuries in cyclists were detected in 13.25% of cases, injuries in the cervical spine prevailed: cervico-occipital injuries and fracture-dislocations, mainly between 1-2 and 3-4 or 6-7 cervical vertebrae with separation or contusion of the spinal cord. Injuries to the structure and organs of the pelvis in road accidents in cyclists were observed very rarely, which made it possible to distinguish this type of bicycle injuries from other types of transport and blunt injuries, in particular from automobile injuries. Injuries to the structure of the limbs of the victims were noted quite often: fractures of the upper limbs occurred when falling on the road surface and injury to the lower limbs was formed both during the contact of two vehicles and when the victims fell on the road surface.

Clinical features and treatment of thoracic trauma in children. Eleven years of experience in a single center

AIM

This study aims to evaluate the characteristics of thoracic trauma in children.

MATERIAL AND METHOD

Thoracic trauma cases treated in our clinic between February 2011 and January 2022 were retrospectively analyzed.

RESULTS

31.5% (n=136) of 432 cases with thoracic trauma had isolated thoracic trauma. Mean age was 8.7±4 years, 74.3% were boys (n=321) and 25.7% were girls (n=111). In patients with thoracic trauma in children; blunt injuries were 84%, penetrating-stab wounds were 12%, and gunshot wounds were 4%, while the rate of penetrating trauma over the age of 15 was 24.8%. The most common causes were motor vehicle accidents (42.4%) and falls from height (23.9%). The most common pathologies; pulmonary contusion (71.7%), pneumothorax (48.7%), rib fracture (18%), and pulmonary laceration (12%). Tube thoracostomy was performed in 51 (46.4%) of 110 cases with pneumothorax. Thoracotomy was performed in 2 cases with penetrating gunshot wounds, and tube thoracostomy was performed in 2 cases with hemothorax. The mean hospital stay was 7 days, and1 case with severe cranial trauma died.

CONCLUSION

Chest wall, pulmonary, mediastinal, and diaphragmatic structures can be damaged in chest trauma. However, it should be kept in mind that every chest trauma patient may also have polytrauma, and accompanying injuries should be carefully examined.

KEY WORDS

Childhood, Thoracic trauma, Tube Thoracostomy.

An investigation of elderly occupant injury risks based on anthropometric changes compared to young counterparts

OBJECTIVE

The objective of the study was to investigate the difference between elderly and young occupant injury risks using human body finite element modeling in frontal impacts.

METHODS

Two elderly male occupant models (representative age 70-80 years) were developed using the Global Human Body Consortium (GHBMC) 50th percentile as the baseline model. In the first elderly model (EM-1), material property changes were incorporated, and in the second elderly model (EM-2), material and anthropometric changes were incorporated. Material properties were based on literature. The baseline model was morphed to elderly anthropometry for EM-2. The three models were simulated in a frontal crash vehicle environment at 56 km/h. Responses from the two elderly and baseline models were compared with cadaver experimental data in thoracic, abdominal, and frontal impacts. Correlation and analysis scores were used for correlation with experimental data. The probabilities of head, neck, and thoracic injuries were assessed.

RESULTS

The elderly models showed a good correlation with experimental responses. The elderly EM-1 had higher risk of head and brain injuries compared to the elderly EM-2 and baseline GHBMC models. The elderly EM-2 demonstrated higher risk of neck, chest, and abdominal injuries than the elderly EM-1 and baseline models.

CONCLUSIONS

The study investigated injury risks of two elderly occupants and compared to a young occupant in frontal crashes. The change in the material properties alone (EM-1) suggested that elderly occupants may be vulnerable to a greater risk of head and thoracic injuries, whereas change in both anthropometric and material properties (EM-2) suggested that elderly occupants may be vulnerable to a greater risk of thoracic and neck injuries. The second elderly model results were in better agreement with field injury data from the literature; thus, both anthropometric and material properties should be considered when assessing the injury risks of elderly occupants. The elderly models developed in this study can be used to simulate different impact conditions and determine injury risks for this group of our population.

Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study

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.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR.

METHODS

A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able.

RESULTS

Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home.

CONCLUSION

Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed.

LEVEL OF EVIDENCE

Therapeutic, Level V.

Chest wall injuries due to cardiopulmonary resuscitation and the effect on in-hospital outcomes in survivors of out-of-hospital cardiac arrest

BACKGROUND

This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries.

METHODS

A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures.

RESULTS

Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively.

CONCLUSION

Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures.

LEVEL OF EVIDENCE

Therapeutic, level IV; Epidemiological, Level IV.

Pediatric surgical rib fixation: A collected case series of a rare entity

BACKGROUND

Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data.

METHODS

Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up.

RESULTS

Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months.

CONCLUSION

Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma.

LEVEL OF EVIDENCE

Collected case series, level V.

Deflection-based parametric survival analysis side impact chest injury risk curves AIS 2015

OBJECTIVES

The objective of this study was to reanalyze lateral postmortem human surrogate (PMHS) sled test chestband data to construct updated lateral thoracic injury risk curves (IRCs) using survival analysis.

METHODS

Chestband and injury data were gathered from 16 previously conducted PMHS sled tests. Briefly, 2 chestbands were wrapped around the thorax's circumference at the levels of ribs 4 and 8. Tests were conducted at 6.7 m/s on a rigid and padded load wall fixed to the top of a rebound sled. The injuries were reclassified using the Abbreviated Injury Scale (AIS) 2015 coding scheme. Chestband signals were combined with pretest specimen measurements to calculate the chest deflection contour time history. Deflections were determined using updated processing techniques calculating the change in length of every point on the contour from the impacted side using the thorax's midpoint as the origin. Four candidate metrics were selected: the deflection from rib 4, the deflection from rib 8, the greater of the deflections from ribs 4 and 8, and the average of the deflections from ribs 4 and 8. AIS 3+ IRCs were developed considering outcomes of AIS ≥3 injuries. All injury data were uncensored, and noninjury data were right-censored. Three specimen mass-based IRCs were determined using the IRC with the lowest Brier score metric (BSM): The first corresponded to the 5th percentile female mass (49 kg), the second to the 50th percentile male mass (77 kg), and the third to the average mass of the PMHS ensemble (65 kg).

RESULTS

Sixteen PMHS were used in the current study. Six specimens were right-censored, and 10 were uncensored. The average metric had the lowest BSM, and mass was a significant covariate with 50% risk of AIS3+ injury at 72mm of chest deflection. The 50% risk deflection magnitudes for the 5th percentile female (49 kg), 50th percentile male (77 kg), and PMHS ensemble (PMHS-E) (65 kg) were 59, 81, and 71 mm. IRCs for the 4 metrics and the 3 occupant masses are given.

CONCLUSIONS

IRCs were developed using survival analysis, and the average of the peak deflections was found to best represent the thoracic chest deflection response. Mass-based side impact IRCs were calculated for occupants representing the WorldSID 5th percentile female and 50th percentile male anthropomorphic test device.

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.

Sports Medicine-Related Breast and Chest Conditions-Update of Current Literature

ABSTRACT

This article reviews the most up-to-date evidence-based recommendations pertaining to breast and upper chest conditions, specifically for the sports medicine physician. Because of the unique circumstances of the team physician, they can see a wide breadth of pathology. Athletes may not have a primary care physician and may prefer to present to their team physician for breast and upper chest conditions. It is often more comfortable and convenient for athletes to seek treatment in the team setting. Therefore, it is important that the medical professional be aware of not only common pathology but also of that which is rarer. Any delay in evaluation can result in unnecessary morbidity and lead to complications or extended time lost from sport. Consequently, it also is important to facilitate an atmosphere encouraging early presentation and workup.

Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report

BACKGROUND

Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious.

CASE PRESENTATION

A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7-10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3-9 on the left side.

CONCLUSION

This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

Severity assessment of accidents involving roadside trees based on occupant injury analysis

The aims of this study were to achieve a quantitative assessment of the severity of accidents involving roadside trees on highways and to propose corresponding safety measures to reduce accident losses. This paper used the acceleration severity index (ASI), head injury criteria (HIC) and chest resultant acceleration (CRA) as indicators of occupant injuries and horizontal radii, vehicle departure speeds, tree diameters and roadside tree spacing as research variables to carry out bias collision tests between cars, trucks and trees by constructing a vehicle rigid body system and an occupant multibody system in PC-crash 10.0® simulation software. A total of 2,256 data points were collected. For straight and curved segments of highways, the occupant injury evaluation models of cars were fitted based on the CRA, and occupant injury evaluation models of trucks and cars were fitted based on the ASI. According to the Fisher optimal segmentation method, reasonable classification standards of severities of accidents involving roadside trees and the corresponding ASI and CRA thresholds were determined, and severity assessment methods for accidents involving roadside trees based on the CRA and ASI were provided. Additionally, a new index by which to evaluate the accuracy of the accident severity classification and the degree of misclassification was built and applied for the validity verification of the proposed severity assessment methods. A proportion of trucks was introduced to further improve the ASI evaluation model. For the same simulation conditions, the results show that driver chest injuries are more serious than driver head injuries and that the average ASI of cars is greater than that of trucks. The CRA and ASI have a positive linear correlation with the departure speed and a logarithmic correlation with the roadside tree diameters. The larger the spacing of roadside trees is and the smaller the horizontal radius is, the smaller the chance that a vehicle will experience a second collision and the lower the risk of occupant injury. In method validation, the evaluation results from two proposed severity assessment methods based on the CRA and ASI are consistent, and the degrees of misclassification are 4.65% and 4.26%, respectively, which verifies the accuracy of the methods proposed in this paper and confirms that the ASI can be employed as an effective index for evaluating occupant injuries in accidents involving roadside trees.

Preliminary injury risk estimation for occupants involved in frontal crashes by combining computer simulations and real crashes

The fatality rate can be dramatically reduced with the help of emergency medical services. The purpose of this study was to establish a computational algorithm to predict the injury severity, so as to improve the timeliness, appropriateness, and efficacy of medical care provided. The computer simulations of full-frontal crashes with rigid wall were carried out using LS-DYNA and MADYMO under different collision speeds, airbag deployment time, and seatbelt wearing condition, in which a total of 84 times simulation was conducted. Then an artificial neural network is adopted to construct relevance between head and chest injuries and the injury risk factors; 37 accident cases with Event Data Recorder data and information on occupant injury were collected to validate the model accuracy through receiver operating characteristic analysis. The results showed that delta-v, seatbelt wearing condition, and airbag deployment time were important factors in the occupant's head and chest injuries. When delta-v increased, the occupant had significantly higher level of severe injury on the head and chest; there is a significant difference of Head Injury Criterion and Combined Thoracic Index whether the occupant wore seatbelt. When the airbag deployment time was less than 20 ms, the severity of head and chest injuries did not significantly vary with the increase of deployment time. However, when the deployment time exceeded 20 ms, the severity of head and chest injuries significantly increased with increase in deployment time. The validation result of the algorithm showed that area under the curve = 0.747, p < 0.05, indicating a medium level of accuracy, nearly to previous model. The computer simulation and artificial neural network have a great potential for developing injury risk estimation algorithms suitable for Advanced Automatic Crash Notification applications, which could assist in medical decision-making and medical care.

Penetrating Thoracic Injury and Fatal Aortic Transection From the Barb of a Stingray

Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.

Adapting load limiter deployment for frontal crash diversity

Objective: Current European restraint systems may not realize their full protection potential in real-world frontal crashes because they are highly optimized for specific conditions. This research sought to quantify the potential benefit of adapting seat belt load limit thresholds to a wider range of occupant and crash characteristics.Methods: Numerical simulations using Hybrid III dummies were conducted to determine how varying load limiter thresholds could affect occupant kinematics and injury outcome in frontal impacts. Occupant-compartment models were developed with a restraint system consisting of a frontal airbag and a 3-point belt with retractor, buckle pretensioner, and load limiting at the shoulder. Load limiting threshold was varied in 5 frontal impact scenarios, covering as wide a range of real frontal crash conditions as possible. The simulated thoracic injury risks were converted into injury probability values using Abbreviated Injury Scale (AIS) 2+ age-dependent thoracic risk curves. These values were then applied to a British real-world frontal impact sample to determine the injury reduction potential of optimized load limiting, taking into account occupant seating position, impact scenario, occupant size, and occupant age and assuming that an appropriate adaptive system was fitted to all cars.Results: In low-severity impacts, a low load limit provided the best chest protection, without increasing risk to other body regions, for both the 50th and 95th percentile dummies in both front seating positions. In high-severity impacts, the low limit was not recommended because it allowed the driver dummy to move into close proximity with the vehicle interior, although there appeared to be some benefit of lower load limiting for the 50th percentile front passenger dummy, due to the increased ride down space in that seating position. Adapting the load limit showed no injury reduction potential for 5th percentile drivers. Utilizing the best load limit threshold in real-world crashes could reduce the number of occupants with AIS 2+ chest injuries from belt loading from 377 to 251 (a 33% reduction), correspondingly reducing the number of occupants with AIS 2+ chest injuries (from all sources) in the whole frontal impact population from 496 to 370. This is a reduction in injury rate from 6.4% to 4.8%.Conclusions: The concept of an adaptive load limiter shows most promise in low-speed frontal crashes where it could lower the AIS 2+ chest injury risk for most front seat occupants, except the smallest of drivers. Generally, adaptive limiters show less potential effectiveness with increased crash severities. Overall, an intelligent adjustment of load limiting threshold could result in a reduction of at least a third of front seat occupants with AIS 2+ chest injuries associated with restraining loads and an overall reduction in AIS 2+ chest injury rate in frontal crashes from 6.4% to 4.8.

Fatal suicidal perforating crossbow bolt injury of the chest

Traumatic injury due to crossbows is a rare occurrence these days. The aim of this study is to present a case of perforating chest injury caused by a bolt shot from a crossbow in suicidal intent which occurred &#8220;live&#8220; during a telephone conversation. The autopsy revealed perforation of the heart and left lungs with massive bleeding to the left pleural cavity which caused haemorrhagic shock. The motive of the mans suicide was the breakup with his girlfriend.

Compression-based injury variables from chestbands in far-side impact THOR sled tests

Objective: This study seeks to determine compression (C_max) and compression-related injury variables (velocity and viscous injury criterion: V_max and VC_max) from chestband data in pure lateral and oblique far-side impact sled tests.Methods: The 3-point belt-restrained mid-sized male Test Device for Human Occupant Restraint (THOR) dummy was placed on a buck and subjected to side impacts with and without center-mounted airbags. The change in velocity was 8.3 m/s for all conditions. Two chestbands were routed around the outer circumference of the THOR at the levels of the third and sixth ribs. Maximum chest deflections were computed using strain gauge signals from the chestbands and their temporal contours. Three methods were used to determine deflection metrics. The first method paralleled methods used in previously published human cadaver studies; the second method used the actual anchor point location and actual alignment of the dummy's internal sensors; and the third method used the anchor location of the internal sensor but determined the sensor's locations on the contour confining to the aspect of the sensor. These 3 approaches are abbreviated as the SD, ID, and TD variables. The injury variables C_max, V_max, and VC_max were determined according to accepted procedures. Their peak magnitudes were extracted and an evaluation of their accuracy was made based on the SD method.Results: The average SD-based C_max magnitudes for the upper and lower chest levels were 0.12 and 0.17 m/s, the V_max magnitudes were 5.3 and 1.8 m/s, and the VC_max magnitudes were 0.24 and 0.15 m/s, respectively. Other data are given for all variables at the 2 levels of the thorax in the body of this paper. The ID-based peak variables were the lowest, and this observation was true regardless of the aspect, right or left side. In contrast, the SD method produced the greatest magnitudes of the variables. The VC_max variable had the greatest normalized difference among all 3 injury variables.Conclusions: Though the present study is limited in scope, the predetermined placement of the internal sensors in the THOR dummy underpredicted chest deflection-related injury variables, and the viscous criterion was the least reliable variable in these lateral and oblique far-side impact sled tests.

Factors associated with chest injuries to front seat occupants in frontal impacts

Objective: Frontal impact chest protection in European cars has been highlighted as an area where possible improvements could be made. The chest is particularly vulnerable in older occupants whose numbers are forecast to increase significantly in the coming decades. This study aimed to provide some direction to areas for possible improvements in frontal crash chest protection.Methods: Real-world crash injury data were interrogated, focusing on cars with current restraint components. The research examined belted front seat occupants in frontal impacts where airbags, pretensioners, and load limiters were present.Results: The chest was the most often injured body region at Abbreviated Injury Scale (AIS) 2+, 3+, and 4+ injury levels. The rate of AIS 2+ and AIS 3+ chest injuries was highest among elderly occupants and lowest among young occupants, and elderly occupants sustained proportionally more severe chest injuries in low/moderate-speed impacts compared to young and middle-aged occupants. However, it should be noted that rates of AIS 2 chest injury were also significantly higher for middle-aged occupants compared to the young. The front passenger seat was shown to be more often associated with significant chest injury than the driver seat. The higher proportion of elderly female occupants was postulated as a reason for this. Skeletal injury was the most frequent type of AIS 2+ chest injury, and the rate of injury for elderly occupants with such injuries was higher than that for young and middle-aged occupants. With the increase in the number of rib fractures, the risk of pulmonary complications and organ injuries tended to increase. The major cause of chest injury was identified as restraining loads transmitted to the chest via the seat belt. The absence of intrusion in the majority of cases suggests an opportunity for the restraint system to better manage the crash pulse, not only for elderly occupants but for those who are middle-aged as well.Conclusions: This study shows the necessity for safety interventions, through new vehicle crashworthiness systems, to improve chest protection, especially for middle-aged and elderly car occupants. Deployment of appropriate injury risk criteria, use of an appropriate dummy thorax, development of a low-energy restraint test, and the development of more adaptive restraints have been discussed as possible solutions to the problem.

Serious injuries secondary to cardiopulmonary resuscitation: incidence and associated factors

OBJECTIVES

To determine the incidence of serious rib cage damage (SRD) and serious visceral damage (SVD) secondary to cardiopulmonary resuscitation (CPR) and to explore associated factors.

MATERIAL AND METHODS

We analyzed data from the prospective registry of cases of sudden death in Tarragona, Spain (the ReCaPTa study). Cases were collected from multiple surveillance sources. In this study we included the cases of autopsied nonsurvivors after attempted manual CPR between April 2014 and May 2016. A specific protocol to detect injuries secondary to CPR was used during the autopsies.

RESULTS

We analyzed 109 cases. The mean age at death was 63 years and 32.1% were women. SRD were found in 63.3% and SVD in 14.7%. The group with SRD were significantly older (63 vs 59 years, P=.031) and included higher percentages of persons with a chest circumference over 101 cm (56.5 vs 30%, P=.016) and a waist circumference over 100 cm (62.3 vs 37.5%, P=.017). A multivariable analysis confirmed chest circumference over 101 cm as the only risk factor for SRD (odds ratio [OR], 2.45; 95% CI, 1.03-5.84) and female sex as the only risk factor for SVD (OR, 5.02; 95% CI, 1.18-21.25).

CONCLUSION

Women and any patient with a chest circumference greater than 101 cm are at greater risk for serious injuries related to CPR.

[Traumatic pancreatic lesions]

In this review, the recommendations for treating pancreatic traumas are summarised. A pancreatic trauma is rare but serious. Initially, the symptoms can be subtle and may easily be overlooked by concurrent injuries such as internal bleeding. Delayed detection of pancreatic lesions is associated with increased mortality and morbidity. There is a tendency towards a more conservative approach in the treatment of pancreatic lesions, including injuries involving the pancreatic duct. In the haemodynamically instable patient damage control surgery is preferred, with closed suction drainage of the pancreas and later definitive surgery. We propose contact to a hepato-pancreato-biliary facility in case of any suspicion of a pancreatic injury.

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.

Differences in durations, adverse events, and outcomes of in-hospital cardiopulmonary resuscitation between day-time and night-time: An observational cohort study

BACKGROUND

Although patients with out-of-hospital cardiac arrest (OHCA) have a lower survival rate during night-time than during day-time, the cause of this difference remains unclear. We aimed to assess CPR parameters according to time period based on in-hospital cardiopulmonary resuscitation (IHCPR) duration and the frequency of iatrogenic chest injuries among OHCA patients.

METHODS

This two-centre observational cohort study evaluated non-traumatic OHCA patients who were transferred between 2013-2016. These patients were categorised according to whether they received day-time treatment (07:00-22:59) or night-time treatment (23:00-06:59). Differences in IHCPR duration, CPR-related chest injuries, return of spontaneous circulation, and survivals to emergency department and hospital discharge were compared using a generalised estimating equation model adjusted for pre-hospital confounders. Sensitivity analysis was also performed using a propensity score matching method.

RESULTS

Among 1254 patients (day-time: 948, night-time: 306), the night-time patients had a significantly shorter IHCPR duration (27.8 min vs. 23.6 min, adjusted difference: -5.1 min, 95% confidence interval [CI]: -6.7, -3.4), a higher incidence of chest injuries (40.4% vs. 67.0%, adjusted odds ratio [AOR]: 1.27, 95% CI: 1.20, 1.35), and a lower rate of return of spontaneous circulation (38.4% vs. 26.5%, AOR: 0.93, 95% CI: 0.88, 0.98). No significant differences were observed in the rates of survival to emergency department and hospital discharge. The propensity score-matched analysis revealed similar results.

CONCLUSIONS

Patients who underwent night-time treatment for OHCA had an increased risk of CPR-related chest injuries despite their shorter resuscitation duration. Further studies are needed to clarify the underlying mechanism(s).

Chest injuries of elderly postmortem human surrogates (PMHSs) under seat belt and airbag loading in frontal sled impacts: Comparison to matching THOR tests

OBJECTIVE

The goal of the study was to develop experimental chest loading conditions that would cause up to Abbreviated Injury Scale (AIS) 2 chest injuries in elderly occupants in moderate-speed frontal crashes. The new set of experimental data was also intended to be used in the benchmark of existing thoracic injury criteria in lower-speed collision conditions.

METHODS

Six male elderly (age >63) postmortem human subjects (PMHS) were exposed to a 35 km/h (nominal) frontal sled impact. The test fixture consisted of a rigid seat, rigid footrest, and cable seat back. Two restraint conditions (A and B) were compared. Occupants were restrained by a force-limited (2.5 kN [A] and 2 kN [B]) seat belt and a preinflated (16 kPa [A] and 11 kPa [B]; airbag). Condition B also incorporated increased seat friction. Matching sled tests were carried out with the THOR-M dummy. Infra-red telescoping rod for the assessment of chest compression (IRTRACC) readings were used to compute chest injury risk. PMHSs were exposed to a posttest injury assessment. Tests were carried out in 2 stages, using the outcome of the first one combined with a parametric study using the THUMS model to adjust the test conditions in the second. All procedures were approved by the relevant ethics board.

RESULTS

Restraint condition A resulted in an unexpected high number of rib fractures (fx; 10, 14, 15 fx). Under condition B, the adjustment of the relative airbag/occupant position combined with a lower airbag pressure and lower seat belt load limit resulted in a reduced pelvic excursion (85 vs. 110 mm), increased torso pitch and a substantially lower number of rib fractures (1, 0, 4 fx) as intended.

CONCLUSIONS

The predicted risk of rib fractures provided by the THOR dummy using the C_max and PC Score injury criteria were lower than the actual injuries observed in the PMHS tests (especially in restraint condition A). However, the THOR dummy was capable of discriminating between the 2 restraint scenarios. Similar results were obtained in the parametric study with the THUMS model.

Assessment of Thoracic Response and Injury Risk Using the Hybrid III, THOR-M, and Post-Mortem Human Surrogates under Various Restraint Conditions in Full-Scale Frontal Sled Tests

A total of 20 full-scale frontal sled tests were conducted using the Hybrid III (HIII), THOR-M and post-mortem human surrogates (PMHSs) to evaluate the thoracic biofidelity of the HIII and THOR-M under various belted restraint conditions. Each surrogate was tested under three belted restraint conditions: knee bolster, knee bolster and steering wheel airbag, and knee bolster airbag and steering wheel airbag. In order to assess the relative biofidelity of each ATD, external thoracic deflections were quantitatively compared between the ATDs and PMHSs using an objective rating metric. The HIII had slightly higher biofidelity than the THOR-M for the external thoracic deflections. Specifically, the THOR-M lower chest was more compliant compared to the other surrogates. However, the THOR-M exhibited expansion of the lower chest opposite belt loading, which was also observed to some degree in the PMHSs. The efficacy of the current injury risk prediction instrumentation and criteria were also evaluated for each surrogate. The THOR-M and its proposed injury risk criteria predicted the injuries observed in the PMHS tests better than the HIII. The PMHS injury criteria over-predicted the amount of chest deflection necessary to produce a severe injury and, consequently, under-predicted injury risk. The results of this study indicate that further testing should be performed to evaluate the biofidelity of the THOR-M thorax under more conditions. Furthermore, current thoracic injury risk criteria, which were developed using censored data, may not be effective at predicting injuries for all restraints and experimental conditions.

Tube Thoracostomy Management in the Combat Wounded

The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 + 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 + 0.7(range 1-4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 + 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097-1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219-12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001-1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03-9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.

Acute myocardial infarction after blunt chest wall trauma with underlying coronary aneurysm: a case report

BACKGROUND

Kawasaki disease is an acute febrile disease with mucocutaneous and cardiovascular involvement affecting infants and young children. Though coronary artery abnormalities are common in Kawasaki disease, no consensus has been reached regarding the treatment of acute coronary artery diseases in this population.

CASE PRESENTATION

We described a case of myocardial infarction triggered by blunt chest wall trauma in a 20 years old girl. She presented with chest pain and breathlessness with brief syncope, lab results and electrocardiogram findings were consistent with acute myocardial infarction. Chest computer tomography (CT) demonstrated coronary artery calcifications and echocardiography revealed multiple giant left anterior descending aneurysms, suggestive of Kawasaki disease. Subsequent contrast enhanced 3 dimensional coronary computer tomography angiography (CTA) confirmed these findings. We managed this young patient with a conservative strategy. The patient remained symptom free during 2-years follow-ups.

CONCLUSIONS

Prompt medical treatment for traumatic myocardial infarction even with underlying giant coronary artery aneurysms can successfully preserve left ventricular function and prevent remodeling with good short term prognosis.

Study of chest injuries to 3-year-old child occupants seated in impact shield and 5-point harness CRSs

OBJECTIVE

The objective of this study was to investigate whether the 5-point harness or the impact shield child restraint system (CRS) or both have the potential to cause chest injuries to children. This is determined by examining whether the loading to the chest reaches the internal organ injury threshold for children.

METHOD

The chest injury risk to a child occupant in a CRS was investigated using Q3 dummy tests, finite element (FE) simulations (Q3 dummy and human models), and animal tests. The investigation was done for 2 types of CRSs (i.e., the impact shield CRS and 5-point harness CRS) based on the UN R44 dynamic test specifications.

RESULTS

The tests using a Q3 dummy indicated that although the chest deflection of the dummy in the impact shield CRS was large, it was less than the injury threshold (40 mm). Computational biomechanics simulations (using finite element FE analysis) showed that the Q3 dummy's chest is loaded by the shield and deforms substantially under this load. To clarify whether chest injuries due to chest compression can occur with an impact shield or with the 5-point harness CRS, 7 experiments were performed using Tibetan miniature pigs with weights ranging from 9.7 to 13 kg. Severe chest and abdominal injuries (lung contusion, coronary artery laceration, liver laceration) were found in the tests using the impact shield CRS. No chest injuries were present when using the 5-point harness CRS.

CONCLUSION

When using the impact shield CRS, the chest deformed substantially in dummy tests and FE simulations, and chest and abdominal injuries were observed in pig tests. It is possible that these chest injuries could also occur to child occupants sitting in the impact shield CRS.

CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015

Background/aim: This study aimed to evaluate traumatic thorax complications in post-CPR patients and to investigate whether or not there has been a decrease in these complications since the adoption of current chest compression recommendations. Materials and methods: Post-CPR patients with return of spontaneous circulation (ROSC) were admitted between January 2014 and January 2016 were analyzed retrospectively. Patients admitted to the ED in 2014 were resuscitated according to 2010 AHA CPR guidelines, while those admitted to the ED in 2015 were resuscitated according to current ERC CPR guidelines. Results: The study population comprised 48 male and 35 female patients. Of the 2010 AHA guideline patients, 39.21% experienced pulmonary contusion, while 54.83% of 2015 ERC guideline patients had pulmonary contusion. It was found that 11.76% of 2010 AHA guideline patients and 3.22% of 2015 ERC guideline patients had pneumothorax, while 9.8% of 2010 AHA guideline patients and 12.9% of 2015 ERC guideline patients experienced hemothorax. Incidence rates of lung contusion, pneumothorax, and hemothorax were higher in patients with rib fractures. Conclusion: In this study, traumatic thoracic complications were investigated in patients with ROSC after CPR. The incidence of CRP-related injuries did not decrease on application of the new 2015 ERC CPR guideline recommendations. The most common injury in this study was rib fracture, followed by sternal fracture, lung contusion, hemothorax, and pneumothorax. Statistically, rib fracture had a positive relationship with lung contusion, hemothorax, and pneumothorax.

Current treatment procedures for civilian gunshot wounds

INTRODUCTION

This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment.

METHOD

We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established.

RESULTS

Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal.

CONCLUSION

Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

Novel Airway and Ventilator Management of Tracheobronchial Disruption After Blunt Trauma

Tracheobronchial injuries can be difficult to diagnose and manage, especially in the presence of polytrauma. A 50-year-old woman presented as a Level I trauma activation after being struck by a motor vehicle. Initial evaluation demonstrated intracranial hemorrhage and multiple chest injuries, including multilevel bilateral rib fractures, pneumomediastinum, and concern for tracheobronchial injury. After initial stabilization, bronchoscopy was performed and demonstrated an injury to the carina. We report a novel airway and ventilation strategy in the setting of concomitant tracheobronchial injury after severe blunt chest trauma in which extracorporeal support is contraindicated.

Management Of Penetrating Injury To Thoracic Inlet And Lower Neck With Retained Foreign Body Using Video Assisted Thoracoscopic Surgery

Penetrating neck and chest injuries are a common form of occupational injuries. We hereby report a unique case in which a metallic rod had penetrated the left chest and neck of a plastic factory worker. The patient was vitally stable when he presented to Emergency Room. Chest X-ray was performed and the patient was rushed to the operating room. VATS (video assisted thoracoscopic surgery) and neck dissection was done for retrieval of the metallic rod. On table, endoscopy was also done to rule out injury to oesophagus. No injury to vital structures was found and the subsequent recovery was uneventful.

Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery

Blunt thoracic aortic injury (BTAI) in a patient with an aberrant right subclavian artery (ARSA) presents unique challenges for patient management and aortic repair. Specific considerations include the need to treat coincidental ARSA, subclavian revascularization, and ARSA exclusion. Despite the rise of endovascular repair as the primary modality for aortic repair for BTAI, reports of this technique in the setting of ARSA are limited. Here we describe 3 patients with ARSA who underwent TEVAR for BTAI, and discuss critical management and technical issues in these patients.

Lateral Thoracic Artery Pseudoaneurysm as a Result of Penetrating Chest Trauma

Pseudoaneurysms are potentially fatal complications of vascular trauma; however, they are rarely seen as the sole complication of penetrating injury. We present a case of a pseudoaneurysm with an associated arteriovenous fistula of the left lateral thoracic artery as a result of direct trauma from a knife stab. The patient presented only with a painful, swollen left pectoralis muscle. Upon diagnosis, he was taken to the interventional radiology suite and treated successfully with fluoroscopic guided coil embolization. Cases such as these are infrequent and should encourage more aggressive use of contrast enhanced computed tomography imaging for soft tissue injury, as a missed traumatic pseudoaneurysm may result in life-threatening hemorrhage.

[Pulmonary contusion]

Pulmonary contusion is a common finding after blunt chest trauma. It occurs in 23-35% of all cases. Alveolar capillaries are injured due to the trauma, which results in accumulation of blood and other fluids within lung tissue. The fluids interfere with gas exchange, leading to hypoxemia. The consequences of pulmonary contusion include ventilation/perfusion mismatching, increased AV shunts and loss of compliance of lung parenchyma. These physiological consequences are manifested within hours from injury and usually resolve in 7 days. Computed tomography (CT) is a sensitive and main diagnostic tool. Clinical symptoms include hypoxemia and hypercapnia, manifested predominantly during 72 hours from injury. Patients are treated primarily conservatively; surgery may be needed due to haemothorax associated with lung contusion or progression of AV shunts due to localized pulmonary contusion.Key words: pulmonary contusion blunt chest trauma computed tomography.

Investigation of chest injury mechanism caused by different seatbelt loads in frontal impact

PURPOSE

The purpose of this quantitative study is to investigate the differences of the injury mechanism caused by two different types of seatbelt loads on the occupant's chest.

METHODS

The finite element analysis is employed to compare the different responses of the human body model, including comparison of kinematics, chest accelerations, seatbelt forces and chest injury outcomes regarding chest deflections and rib fractures.

RESULTS

The calculated rib strain-stress response from simulations in force-limiting seatbelt are higher than that in the regular seatbelt. The forward movement and torso twist are both great in simulations with force-limiting seatbelt. Moreover, there are obvious differences in the injury outcomes of chest deflections and rib fracture risks under the different seatbelt loads.

CONCLUSION

Results indicate that the chest deflections and rib fracture risks are negatively correlated under the load of the force-limiting seatbelt, However, they are positively correlated to and determined by the seatbelt peak load of the regular seatbelt. This paper can provide a reference for study of the chest injury mechanism and protection efficiency of seatbelt.