-
European Journal of Trauma and... Oct 2022The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. (Review)
Review
PURPOSE
The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.
METHODS
A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14 of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications.
RESULTS
Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).
CONCLUSION
Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.
Topics: Clavicle; Humans; Length of Stay; Multiple Trauma; Retrospective Studies; Rib Fractures; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 34075434
DOI: 10.1007/s00068-021-01701-4 -
Scandinavian Journal of Trauma,... Aug 2018Major Trauma remains a leading cause of mortality and morbidity worldwide. Blunt Thoracic Injury (BTI) accounts for > 15% of United Kingdom (UK) trauma admissions and... (Review)
Review
BACKGROUND
Major Trauma remains a leading cause of mortality and morbidity worldwide. Blunt Thoracic Injury (BTI) accounts for > 15% of United Kingdom (UK) trauma admissions and is consistently associated with respiratory related complications that include pneumonia and respiratory failure. Despite this, it is unclear in current clinical practice how BTI impacts on the recovering trauma patients after discharge from hospital. This study aimed to investigate the state of knowledge on the impact of BTI on the long-term outcomes and health-related quality of life (HRQoL).
METHODS
Data were sourced from Ovid MEDLINE, Ovid EMBASE, CINAHL and Science Direct using a pre-defined systematic search strategy. A subsequent hand search of key references was used to identify potentially missed studies. Abstracts were screened for eligibility and inclusion. Fifteen studies met the eligibility criteria and were critically appraised. Data were extracted, analysed and synthesised in categories and sub-categories following a narrative approach.
RESULTS
Three major themes were identified from the 15 studies included in this review: (i) physical impact of BTI, (ii) psychological impact of BTI and (iii) socio-economic impact of BTI. The bulk of the available data focused on the physical impact where further sub-themes included: (i) physical functioning, (ii) ongoing unresolved pain, (iii) reduced respiratory function, (iv) thoracic structural integrity. Although there was a substantial difference in the length and method of follow up, there remains a general trend towards physical symptoms improving over time, particularly over the first six months after injury. Despite this, where sequelae continued at six months it remained likely that these would also be present at two years after injury.
CONCLUSION
The literature review demonstrated that BTI is associated with substantial sequelae that impacts on all aspects of daily functioning. Despite this there remains a paucity of data relating to long term outcomes in the BTI population, especially relating to psychological and socio-economic impact. There is also little consensus on the measures, tools and time-frames used to measure outcomes and HRQoL in this population. The full impact of BTI on this population needs further exploration.
Topics: Health Status; Hospitalization; Humans; Outcome Assessment, Health Care; Quality of Life; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 30119640
DOI: 10.1186/s13049-018-0535-9 -
Respiratory Care Sep 2022Blunt pulmonary contusions are associated with severe chest injuries and are independently associated with worse outcomes. Previous preclinical studies suggest that...
BACKGROUND
Blunt pulmonary contusions are associated with severe chest injuries and are independently associated with worse outcomes. Previous preclinical studies suggest that contusion progression precipitates poor pulmonary function; however, there are few current clinical data to corroborate this hypothesis. We examined pulmonary dynamics and oxygenation in subjects with pulmonary contusions to evaluate for impaired respiratory function.
METHODS
A chest injury database was reviewed for pulmonary contusions over 5 years at an urban trauma center. This database was expanded to capture mechanical ventilation parameters for the first 7 days on all patients with pulmonary contusion and who were intubated. Daily [Formula: see text]:[Formula: see text], oxygenation indexes (OI), and dynamic compliances were calculated. Pulmonary contusions were stratified by severity. The Fisher exact and chi square tests were performed on categorical variables, and Mann-Whitney U-tests were performed on continuous variables. Significance was assessed at a level of 0.05.
RESULTS A TOTAL OF
1,176 patients presented with pulmonary contusions, of whom, 301 subjects (25.6%) required intubation and had available invasive mechanical ventilation data. Of these, 144 (47.8%) had mild-moderate pulmonary contusion and 157 (52.2%) had severe pulmonary contusion. Overall injury severity score was high, with a median injury severity score of 29 (interquartile range, 22-38). The median duration of mechanical ventilation for mild-moderate pulmonary contusion was 7 d versus 10 d for severe pulmonary contusion ( = .048). All the subjects displayed moderate hypoxemia, which worsened until day 4-5 after intubation. Severe pulmonary contusion was associated with significantly worse early hypoxia on day 1 and day 2 versus mild-moderate pulmonary contusion. Severe pulmonary contusion also had a higher oxygenation index than mild-moderate pulmonary contusion. This trend persisted after adjustment for other factors, including transfusion and fluid administration.
CONCLUSIONS
Pulmonary contusions played an important role in the course of subjects who were acutely injured and required mechanical ventilation. Contusions were associated with hypoxemia not fully characterized by [Formula: see text]: [Formula: see text], and severe contusions had durable elevations in the oxygenation index despite confounders.
Topics: Contusions; Humans; Hypoxia; Lung; Lung Injury; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 35728821
DOI: 10.4187/respcare.09913 -
Journal of Vascular Surgery Mar 2022Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with... (Observational Study)
Observational Study
Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry.
BACKGROUND
Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.
METHODS
The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (<6 vs ≥6 hours) or urgent (<24 vs ≥24 hours) intervals.
RESULTS
A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (<6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (<24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke.
CONCLUSIONS
In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.
Topics: Adult; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Brain Injuries, Traumatic; Clinical Decision-Making; Endovascular Procedures; Female; Hemodynamics; Hospital Mortality; Humans; Male; Middle Aged; Multiple Trauma; Postoperative Complications; Prospective Studies; Registries; Risk Assessment; Risk Factors; Thoracic Injuries; Time Factors; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 34606963
DOI: 10.1016/j.jvs.2021.09.028 -
Operative Orthopadie Und Traumatologie Jun 2021Surgical stabilization of patients with flail chest, dislocated serial rib and sternal fractures, posttraumatic deformities of the thorax, symptomatic non-unions of the...
OBJECTIVE
Surgical stabilization of patients with flail chest, dislocated serial rib and sternal fractures, posttraumatic deformities of the thorax, symptomatic non-unions of the ribs and/or sternum, and weaning failure to biomechanically stabilize the thorax and avoid respirator-dependent complications.
INDICATIONS
Combination of clinically and radiologically observed parameters, such as pattern of thoracic injuries, grade of fracture dislocation, pathological changes to breathing biomechanics, and failure of nonsurgical treatment.
CONTRAINDICATIONS
Acute hemodynamical instability and signs of systemic infection.
SURGICAL TECHNIQUE
Detailed preoperative planning. Open, minimally invasive reduction and osteosynthesis using precontoured, low-profile locking plates and/or intramedullary splints. Careful reduction drilling/implantation of screws due to proximity of the pleura, lungs and pericardium.
POSTOPERATIVE MANAGEMENT
Weaning from respirator as early as possible and early therapy of pneumothorax perioperatively. Removal of implants usually not necessary.
RESULTS
In a retrospective study, 15 polytraumatized patients with flail chest benefitted from an early interdisciplinary surgical treatment strategy within 24-48 h. Early osteosynthesis after severe thoracic trauma significantly reduced ventilator dependency and lowered the risk of pneumonia compared to patients who underwent surgery at a later time point. Patients with severe thoracic injury and life-threatening polytrauma, who meet the indication criteria for open reduction and surgical stabilization of the thorax, are in need of a throughly planned and interdisciplinary synchronized priorization and strategy. Longer intensive care unit stay, overall prolonged duration of admission in hospital, and higher level of respirator-associated complication should be expected in patients with life-threatening severe thoracic trauma (Abbreviated Injury Score (AIS) ≥ 3) compared to patients without thoracic trauma.
Topics: Flail Chest; Fracture Fixation, Internal; Humans; Retrospective Studies; Rib Fractures; Thoracic Wall; Treatment Outcome
PubMed: 33289872
DOI: 10.1007/s00064-020-00688-2 -
Pediatric Surgery International Oct 2021This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without...
PURPOSE
This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI).
METHODS
All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study.
RESULTS
A total of 75 patients with a median age of 11 [6-13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no difference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI.
CONCLUSION
In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence.
Topics: Adolescent; Brain Injuries, Traumatic; Child; Humans; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Distress Syndrome; Retrospective Studies; Thoracic Injuries
PubMed: 34232362
DOI: 10.1007/s00383-021-04959-2 -
Current Opinion in Pulmonary Medicine Jul 2015In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with... (Review)
Review
PURPOSE OF REVIEW
In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs.
RECENT FINDINGS
In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes.
SUMMARY
Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
Topics: Animals; Hemothorax; Humans; Length of Stay; Postoperative Period; Thoracic Injuries; Thoracic Surgery, Video-Assisted; Wounds, Nonpenetrating
PubMed: 25978625
DOI: 10.1097/MCP.0000000000000173 -
Scandinavian Journal of Trauma,... Apr 2017Thoracic trauma is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. The purpose of this study was to investigate... (Review)
Review
BACKGROUND
Thoracic trauma is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. The purpose of this study was to investigate epidemiological data, treatment and outcome of polytrauma patients with blunt chest trauma in order to help improve management, prevent complications and decrease polytrauma patients' mortality.
METHODS
In this retrospective study we included all polytrauma patients with blunt chest trauma admitted to our tertiary care center emergency department for a 2-year period, from June 2012 until May 2014. Data collection included details of treatment and outcome. Patients with chest trauma and Injury Severity Score (ISS) ≥18 and Abbreviated Injury Scale (AIS) >2 in more than one body region were included.
RESULTS
A total of 110 polytrauma patients with blunt chest injury were evaluated. 82 of them were males and median age was 48.5 years. Car accidents, falls from a height and motorbike accidents were the most common causes (>75%) for blunt chest trauma. Rib fractures, pneumothorax and pulmonary contusion were the most common chest injuries. Most patients (64.5%) sustained a serious chest injury (AIS 3), 19.1% a severe chest injury (AIS 4) and 15.5% a moderate chest injury (AIS 2). 90% of patients with blunt chest trauma were treated conservatively. Chest tube insertion was indicated in 54.5% of patients. The need for chest tube was significantly higher among the AIS 4 group in comparison to the AIS groups 3 and 2 (p < 0.001). Also, admission to the ICU was directly related to the severity of the AIS (p < 0.001). The severity of chest trauma did not correlate with ICU length of stay, intubation days, complications or mortality.
CONCLUSION
Although 84.5% of patients suffered from serious or even severe chest injury, neither in the conservative nor in the surgically treated group a significant impact of injury severity on ICU stay, intubation days, complications or mortality was observed. AIS was only related to the rate of chest tube insertions and ICU admission. Management with early chest tube insertion when necessary, pain control and chest physiotherapy resulted in good outcome in the majority of patients.
Topics: Abbreviated Injury Scale; Adolescent; Adult; Aged; Aged, 80 and over; Female; Humans; Injury Severity Score; Male; Middle Aged; Multiple Trauma; Retrospective Studies; Thoracic Injuries; Trauma Centers; Wounds, Nonpenetrating; Young Adult
PubMed: 28427480
DOI: 10.1186/s13049-017-0384-y -
The Cochrane Database of Systematic... Jan 2015Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also... (Review)
Review
BACKGROUND
Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery.
OBJECTIVES
To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery.
SEARCH METHODS
We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators.
SELECTION CRITERIA
Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration.
MAIN RESULTS
Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002).
AUTHORS' CONCLUSIONS
Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.
Topics: Abdominal Injuries; Adult; Blood Transfusion; Female; Humans; Male; Middle Aged; Mortality; Operative Blood Salvage; Randomized Controlled Trials as Topic; Thoracic Injuries
PubMed: 25613473
DOI: 10.1002/14651858.CD007379.pub2 -
European Journal of Vascular and... Jan 2006Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with... (Review)
Review
Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.
Topics: Aorta, Thoracic; Aortic Diseases; Echocardiography, Transesophageal; Humans; Radiography, Thoracic; Rupture; Thoracic Injuries; Time Factors; Tomography, X-Ray Computed; Trauma Severity Indices; Treatment Outcome; Vascular Surgical Procedures; Wounds, Nonpenetrating
PubMed: 16226902
DOI: 10.1016/j.ejvs.2005.06.031