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European Journal of Trauma and... Apr 2023The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes.
PURPOSE
The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes.
METHODS
A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included.
RESULTS
Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007).
CONCLUSION
Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort.
Topics: Humans; Male; Adult; Middle Aged; Aged; Female; Flail Chest; Rib Fractures; Thoracic Injuries; Hospitalization; Respiration, Artificial; Retrospective Studies; Length of Stay; Fracture Fixation, Internal
PubMed: 36318281
DOI: 10.1007/s00068-022-02152-1 -
Journal of Vascular Surgery Feb 2022Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical...
OBJECTIVE
Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical management (MM) for BTAI. We hypothesized from the results of several previously reported studies, that patients with a minimal aortic injury (BTAI grades 1 and 2) could safely be treated with definitive MM alone.
METHODS
The Aortic Trauma Foundation international prospective multicenter registry was used to examine the demographics, injury characteristics, management, and outcomes of patients with BTAI. We analyzed a subset of patients for whom MM was initiated as definitive therapy.
RESULTS
From November 2016 to April 2020, 432 patients (median age, 41 years; 76% male; median injury severity score, 34) with BTAI (Society for Vascular Surgery grade 1, 23.6%; grade 2, 14.4%; grade 3, 51.2%; grade 4, 10.9%) were evaluated. Of the 432 patients, 245 (57%) had received MM in the initial period and 114 (26.4%) had received MM as the planned definitive therapy (grade 1, 59.6%; grade 2, 23.7%; grade 3, 15.8%; grade 4, 0.9%). The most common mechanism of BTAI was a motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was used for 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) the most common agent used. Treatments were targeted to a goal systolic blood pressure for 83.3%, most often to a target goal systolic blood pressure <120 mm Hg (66.3%). The MM goals based on blood pressure control were attained in 64.0% (73 of 114). Twelve patients (10.5%; grade 1, 1; grade 2, 0; grade 3, 10; grade 4, 1) had required subsequent intervention after MM. Eleven patients (9.6%) had undergone thoracic endovascular aortic repair and one (0.9%) had required open repair for a grade 4 injury. The overall in-hospital mortality for patients selected for definitive MM was 7.9%. No aortic-related deaths had occurred in the patients receiving definitive MM.
CONCLUSIONS
Approximately one in four patients with BTAI will receive MM as definitive therapy. The variation in the pharmacologic therapies used is considerable. MM for patients with minimal aortic injury (BTAI grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support the use of definitive MM for grade 2 BTAI.
Topics: Adult; Aorta, Thoracic; Disease Management; Endovascular Procedures; Female; Follow-Up Studies; Hospital Mortality; Humans; Incidence; Injury Severity Score; Male; Middle Aged; Prospective Studies; Registries; Thoracic Injuries; Treatment Outcome; United States; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 34560220
DOI: 10.1016/j.jvs.2021.08.084 -
Chirurgie (Heidelberg, Germany) Sep 2023Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and...
BACKGROUND
Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.
OBJECTIVE
The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.
MATERIAL AND METHODS
In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.
RESULTS
A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.
CONCLUSION
Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.
Topics: Humans; Rib Fractures; Retrospective Studies; Wounds, Nonpenetrating; Thoracic Injuries; Lung Injury; Contusions; Abdominal Injuries
PubMed: 37268786
DOI: 10.1007/s00104-023-01891-0 -
European Review For Medical and... Jun 2021We aimed at investigating the effects of clinical data, urgent thoracotomy (UT) indications and results on prognosis and mortality in traumatic and non-traumatic...
OBJECTIVE
We aimed at investigating the effects of clinical data, urgent thoracotomy (UT) indications and results on prognosis and mortality in traumatic and non-traumatic patients who were and underwent UT in the operating room.
PATIENTS AND METHODS
Patients (17-90 years old) who were admitted to the Emergency Department of Afyonkarahisar State Hospital between 01.01.2012 and 31.06.2020 with traumatic and non-traumatic reasons requiring UT were retrospectively conducted from the archive. The patients' age, gender, complaints during admission, trauma classification, reports of thorax images, injury sites accompanying trauma, hospitalization and mortality rates were examined. IBM SPSS 22.0 program was used to compare all the data obtained.
RESULTS
During the 90-month study period, a total of 40 patients who were admitted for traumatic and non-traumatic reasons were applied UT. The mean age of all patients (77.5% male, 22.5% female) was 33.35±14.1 years. There were 55% penetrating injuries, 32.5% blunt injuries and 12.5% non-traumatic causes. Indications for UT in the study were; massive hemothorax (25%), diaphragmatic rupture (22.5 %), hypovolemic shock (25%), heart or great vessel injuries (15%), massive air leak despite thoracostomy (10%), rupture of the pulmonary hydatid cyst into the bronchus and accompanying hemoptysis (2.5%). The time to surgical procedure in patients who underwent thoracotomy was shorter in patients with death. Mean time to thoracotomy was 4.5±6.5 hours. Mortality of UT was 20% with survival of 80%.
CONCLUSIONS
In the context of indications, urgent thoracotomy reduces mortality. The cooperation between the emergency physician and the thoracic surgeon is important during the decision phase.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Emergency Service, Hospital; Female; Hospitalization; Humans; Male; Middle Aged; Prognosis; Thoracic Injuries; Thoracotomy; Wounds, Nonpenetrating; Wounds, Penetrating; Young Adult
PubMed: 34227069
DOI: 10.26355/eurrev_202106_26143 -
BMJ Case Reports Mar 2022Blunt thoracic aortic injury (BTAI) is an uncommon yet serious diagnosis in trauma patients, with high on-scene mortality. BTAI typically occurs from rapid deceleration...
Blunt thoracic aortic injury (BTAI) is an uncommon yet serious diagnosis in trauma patients, with high on-scene mortality. BTAI typically occurs from rapid deceleration such as in motor vehicle collisions or high-altitude falls shearing the aorta just proximal to the ligamentum arteriosum. We report a case of a man in his 50s falling from a height of 15 m who presented hypotensive with retrosternal chest pain. Mobile chest X-ray showed a widened mediastinum with left-sided haemothorax. CT revealed a contained free aortic rupture just inferior to the origin of the left subclavian artery with bleeding into the mediastinum and left pleural space. The patient underwent urgent thoracic endovascular aortic repair (TEVAR) but arrested on-table due to a left-sided tension haemothorax requiring chest-drain decompression and haemostatic resuscitation. After return of spontaneous circulation, TEVAR was successfully performed. BTAI is a dynamic process; hence, timely imaging and minimally invasive surgical treatment are key to patients surviving grade III and IV aortic injuries.
Topics: Aorta; Endovascular Procedures; Heart Arrest; Humans; Male; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 35351753
DOI: 10.1136/bcr-2021-248211 -
Academic Emergency Medicine : Official... Jul 2018Scapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary...
BACKGROUND
Scapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary contusion, and rib fracture, increased chest computed tomography (CT) utilization and head-to-pelvis CT (pan-scan) protocols in blunt trauma evaluation, however, may diagnose minor, clinically irrelevant scapular fractures, possibly rendering previous teachings obsolete.
OBJECTIVES
The objectives were to determine the 1) percentages of scapular fractures seen on chest CT only (SOCTO) versus seen on both chest x-ray (CXR) and CT and of isolated scapular fracture (scapular fracture without other thoracic injuries); 2) frequencies of associated thoracic injury with scapular fracture; and 3) proportion of patients admitted, mortality, hospital length of stay, and injury severity scores (ISS), comparing four patient groups: scapular fracture, nonscapular fracture, scapular fracture SOCTO, and isolated scapular fracture.
METHODS
We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest CT study at nine Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation.
RESULTS
Of 11,477 subjects, 4,501 (39.2%) patients who had both CXR and chest CT and 2.7% of these had scapular fractures; 60.3% of these were SOCTO and 23 (19.0%) were isolated scapular fracture. The most commonly associated thoracic injuries were rib fracture, pulmonary contusion, pneumothorax, and thoracic spine fracture and all injuries were more common in scapular fracture patients than nonscapular fracture patients. Although scapular fracture patients had higher admission rates (86.8% vs. 47.4%; difference in proportions = 39.4% [95% confidence interval {CI} = 32.8% to 44.1%]), ISS (21 vs. 5), and length of stay (9.2 days vs. 5.6 days; mean difference = 3.4 days [95% CI = 2.1 to 4.7 days]) than patients without scapular fracture, their hospital mortality was not significantly different (5.6% vs. 3.0%; difference in proportions = 2.6% [95% CI = -8.2% to 0.3%]; unadjusted odds ratio = 1.9 [95% CI = 0.9 to 4.2]). Patients with scapular fracture SOCTO and isolated scapular fracture had higher admission rates and median ISS than nonscapular fracture patients, but their mortality was similar.
CONCLUSIONS
Under current blunt trauma imaging protocols that commonly include chest CT, most scapular fractures are SOCTO and most are associated with other thoracic injuries. Although patients with scapular fracture SOCTO and isolated scapular fracture have higher admission rates and ISS than nonscapular fracture patients, their hospital mortality is similar.
Topics: Adult; Case-Control Studies; Female; Fractures, Bone; Hospital Mortality; Humans; Injury Severity Score; Male; Middle Aged; Patient Admission; Prospective Studies; Scapula; Thoracic Injuries; Tomography, X-Ray Computed; Trauma Centers; Wounds, Nonpenetrating; Young Adult
PubMed: 29322585
DOI: 10.1111/acem.13377 -
European Journal of Trauma and... Feb 2022Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of...
PURPOSE
Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center.
METHODS
Data of 168 patients' ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed.
RESULTS
Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods.
CONCLUSIONS
Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma.
Topics: Accidents, Traffic; Adolescent; Adult; Child; Humans; Injury Severity Score; Retrospective Studies; Thoracic Injuries; Trauma Centers
PubMed: 33813596
DOI: 10.1007/s00068-021-01658-4 -
Scientific Reports Dec 2020Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant...
Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.
Topics: Acromioclavicular Joint; Adult; Arm Injuries; Case-Control Studies; Female; Humans; Joint Dislocations; Male; Middle Aged; Registries; Severity of Illness Index; Sternoclavicular Joint; Thoracic Injuries
PubMed: 33303859
DOI: 10.1038/s41598-020-78754-9 -
World Journal of Emergency Surgery :... Sep 2022Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury,...
BACKGROUND
Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.
METHODS
This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.
RESULTS
We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22-35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18-44) and 17 (10-27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77-23. 43), and visible contamination (OR 5.13, 95% IC 1.26-20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.
CONCLUSION
The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.
Topics: Adult; Empyema; Humans; Male; Risk Factors; Thoracic Injuries; Thoracotomy; Wounds, Penetrating
PubMed: 36100861
DOI: 10.1186/s13017-022-00453-9 -
Chirurgia (Bucharest, Romania : 1990) Dec 2022Management protocols for patients with penetrating cardiac injury have undergone a dramatic transition during the last decades. However, even today cardiac trauma...
Management protocols for patients with penetrating cardiac injury have undergone a dramatic transition during the last decades. However, even today cardiac trauma remains a major medical problem. Retrospective single-center case series study, 41 patients with precordial wounds hospitalized at the Institute of Emergency Medicine, Chisinau, period 2005-2020. Mean age - 45.8 Ã+- 8.9 years, M:F/19.5:1. Traumatic event: stabbing (82.9%,n=34) or gunshot wound (17.1%,n=7). Preoperative paraclinical examinations: electrocardiography, chest X-ray, FAST, pleurotomy, pericardial puncture, and thoracoscopy. 36 (87.8%) patients were hemodynamically unstable on hospitalization, and 19 (52.8%) were immediately transferred to the operating room. Preferred surgical access: left anterolateral thoracotomy - 26 (63.4%), right anterolateral thoracotomy - 13 (31.7%), and left posterolateral thoracotomy - 2 (4.9%). Non-penetrating lesions were discovered in 5 (12.2%) while penetrating trauma in other 36 (87.8%) cases, most frequently the right ventricle being injured. Additional intrathoracic lesions discovered in 29 (70.7%) patients: pulmonary parenchyma rupture - 25 (86.2%), internal mammary artery injury - 3 (10.3%), and intercostal artery injury - 1 (3.5%). The average length of stay was 13.2 Ã+- 4 days, including stay in the Intensive Care Unit - 2.9 Ã+- 1.2. Mortality rate -17.1% (n=7). Successful cardiac suture determined the survival rate of 82.9%. Lethality increases proportionally to the severity of the cardiac injury, the volume of blood loss, and damage to the right vs left heart chambers.
Topics: Humans; Middle Aged; Wounds, Gunshot; Retrospective Studies; Treatment Outcome; Wounds, Penetrating; Heart Injuries; Thoracic Injuries; Thoracotomy; Wounds, Stab
PubMed: 36584058
DOI: 10.21614/chirurgia.2725