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Chinese Journal of Traumatology =... Jun 2020Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four... (Review)
Review
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
Topics: Flail Chest; Hemothorax; Humans; Lung Injury; Pain Management; Pneumothorax; Rib Fractures; Thoracic Injuries; Thoracic Wall; Wounds, Nonpenetrating
PubMed: 32417043
DOI: 10.1016/j.cjtee.2020.04.003 -
Anaesthesia Feb 2023Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and... (Review)
Review
Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.
Topics: Humans; Thoracic Injuries; Pain; Pain Management; Analgesia; Lung
PubMed: 36572548
DOI: 10.1111/anae.15934 -
JAMA Surgery Nov 2022Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared...
IMPORTANCE
Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.
OBJECTIVE
To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.
DESIGN, SETTING, AND PARTICIPANTS
This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.
INTERVENTIONS
Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.
MAIN OUTCOMES AND MEASURES
The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).
RESULTS
A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.
CONCLUSIONS AND RELEVANCE
The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01367951.
Topics: Humans; Male; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Rib Fractures; Prospective Studies; Thoracic Wall; Treatment Outcome; Thoracic Injuries; Length of Stay; Respiration, Artificial
PubMed: 36129720
DOI: 10.1001/jamasurg.2022.4299 -
World Journal of Emergency Surgery :... May 2023The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains.
AIM OF THE STUDY
To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician.
METHODS
A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I and the QUADAS-2 tool was used to assess bias of the studies.
RESULTS
This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries.
CONCLUSION
Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.
Topics: Humans; Thoracic Injuries; Wounds, Nonpenetrating; Heart Injuries; Myocardial Contusions; Troponin I; Troponin T; Diagnostic Tests, Routine
PubMed: 37245048
DOI: 10.1186/s13017-023-00504-9 -
Journal of Cardiothoracic Surgery Feb 2023Blunt cardiac injury (BCI) encompasses a spectrum of pathologies ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. Of diagnosed BCIs,... (Review)
Review
Blunt cardiac injury (BCI) encompasses a spectrum of pathologies ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. Of diagnosed BCIs, cardiac contusion is most common. Suggestive symptoms may be unrelated to BCI, while some injuries may be clinically asymptomatic. Cardiac rupture is the most devastating complication of BCI. Most patients who sustain rupture of a heart chamber do not reach the emergency department alive. The incidence of BCI following blunt thoracic trauma remains variable and no gold standard exists to either diagnose cardiac injury or provide management. Diagnostic tests should be limited to identifying those patients who are at risk of developing cardiac complications as a result of cardiac in jury. Therapeutic interventions should be directed to treat the complications of cardiac injury. Prompt, appropriate and well-orchestrated surgical treatment is invaluable in the management of the unstable patients.
Topics: Humans; Heart Injuries; Heart; Myocardial Contusions; Heart Rupture; Wounds, Nonpenetrating; Rupture; Thoracic Injuries
PubMed: 36765392
DOI: 10.1186/s13019-023-02146-z -
Ulusal Travma Ve Acil Cerrahi Dergisi =... May 2022The objective of the study is to investigate diagnostic and clinical processes performed for cardiac contusion in patients with blunt thoracic trauma.
BACKGROUND
The objective of the study is to investigate diagnostic and clinical processes performed for cardiac contusion in patients with blunt thoracic trauma.
METHODS
This study was conducted retrospectively on 65 patients admitted with isolated blunt thoracic trauma to the Emergency Medicine Department. The CT images, the cardiac enzyme levels, the periodic 4-h follow-up electrocardiography (ECGs) in the emer-gency department, and the results of echocardiography, performed at admission and when required according to the clinical status, were investigated. The 1-h and 4-h high-sensitivity troponin I levels were studied, and values above 0.04 ng/ml were considered as positive.
RESULTS
Sixty-five patients with isolated thoracic trauma were included in the study, 23 (35.38%) had pulmonary and cardiac contu-sions both. In 23 (35.38%) patients, pulmonary contusion had been present, and cardiac contusion had not been identified at the initial evaluation. However, during clinical follow-up, troponin became positive, dysrhythmia developed, and the trauma affected the heart in four of these patients. In six (9.24%) patients, cardiac contusion was identified without pulmonary contusion. In 13 (20%) patients, no cardiac or pulmonary contusion was identified. troponin elevation was detected in 10 patients without a diagnosis of cardiac contusion who had a pulmonary contusion, hemothorax, and/or pneumothorax at the time of hospital admission and then with normal troponin levels at 4-h control. We found that there was a statistical agreement between cardiac contusion and troponin-ECG results at 4th h.
CONCLUSION
We advise that all blunt thoracic trauma patients should be screened for cardiac contusion by continuous ECG monitoring and troponin levels.
Topics: Attention; Contusions; Humans; Lung Injury; Myocardial Contusions; Retrospective Studies; Thoracic Injuries; Troponin I; Wounds, Nonpenetrating
PubMed: 35485460
DOI: 10.14744/tjtes.2021.11290 -
European Journal of Trauma and... Apr 2023Thoracic trauma accounts for 25-50% of posttraumatic mortality. Data on epidemiology of thoracic trauma in Scandinavia and risk factors for mortality are scarce. This...
PURPOSE
Thoracic trauma accounts for 25-50% of posttraumatic mortality. Data on epidemiology of thoracic trauma in Scandinavia and risk factors for mortality are scarce. This study aims to provide an overview of epidemiology, clinical events and risk factors for mortality of patients with severe thoracic injuries.
METHODS
A retrospective study including adult thoracic trauma patients with abbreviated injury scale ≥ 3, between 2009 and 2018 at Haukeland University Hospital was performed. Subgroup analyses were performed for specific patient groups: (1) isolated thoracic trauma, (2) polytrauma without Traumatic Brain Injury (TBI) and (3) polytrauma with TBI. Logistic regression analyses were applied to find risk factors for 30-days mortality. Age, sex, comorbidity polypharmacy score (CPS), trauma and injury severity score (TRISS) and comprehensive complication index (CI) were included in the final model.
RESULTS
Data of 514 patients were analyzed, of which 60 (12%) patients died. Median (IQR) injury severity score (ISS) was 17 (13-27). Data of 463 patients, of which 39 patients died (8%), were included in multivariate analyses. Female sex odds ratio (OR) (2.7, p = 0.04), CPS > 9 (OR 4.8; p = 0.01), TRISS ≤ 50% (OR 44; p < 0.001) and CI ≥ 30 (OR 12.5, p < 0.001) were significant risk factors for mortality. Subgroup analyses did not demonstrate other risk factors.
CONCLUSION
Comorbidities and associated pharmacotherapies, TRISS, female sex, and complications during admission predict in-hospital mortality after thoracic trauma. Current findings might help to recognize patients at risk of an adverse outcome, and thereby prevent complications.
TRIAL REGISTRATION
RETROSPECTIVELY REGISTERED: The regional committees for medical and health research ethics file number is 2017/293.
Topics: Adult; Humans; Female; Retrospective Studies; Thoracic Injuries; Multiple Trauma; Injury Severity Score; Comorbidity
PubMed: 36527498
DOI: 10.1007/s00068-022-02177-6 -
Revista Da Associacao Medica Brasileira... 2022We investigated the relationship between thoracic diameters and chest compression-related thoracoabdominal injury in patients with non-traumatic out-of-hospital cardiac...
OBJECTIVE
We investigated the relationship between thoracic diameters and chest compression-related thoracoabdominal injury in patients with non-traumatic out-of-hospital cardiac arrest who had a return of spontaneous circulation after cardiopulmonary resuscitation.
METHODS
A total of 63 consecutive adult non-traumatic out-of-hospital cardiac arrest patients were enrolled in this prospective study. Computed tomography was performed on each patient and the anteroposterior diameter, skin-to-skin anteroposterior diameter, and transverse diameter of the chest were measured. Patients were divided into two groups based on the presence or absence of cardiopulmonary resuscitation-related thoracoabdominal injury. Age, sex, and duration of cardiopulmonary resuscitation, anteroposterior diameter, skin-to-skin anteroposterior diameter, and transverse diameter were compared between the groups. The primary outcome was the relationship between thoracic diameters and cardiopulmonary resuscitation-induced thoracoabdominal injuries.
RESULTS
Thoracoabdominal injuries were detected in 46% (n=29) of the patients and consisted of rib fractures in 22 (34.9%) patients, pulmonary contusion in 7 (11.1%), and sternal fracture in 3 (4.8%) patients. There were no significant differences in cardiopulmonary resuscitation duration between patients with and without thoracoabdominal injuries (p=0.539). Similarly, there were no significant differences in anteroposterior diameter, skin-to-skin anteroposterior diameter, or transverse diameter between patient groups (p=0.978, p=0.730, and p=0.146, respectively) or between patients who died within the first 28 days and those who survived for longer than 28 days (p=0.488, p=0.878, and p=0.853, respectively).
CONCLUSION
The iatrogenic thoracoabdominal injuries caused by cardiopulmonary resuscitation performed according to the cardiopulmonary resuscitation guidelines were independent of thoracic diameters. Therefore, the cardiac compression depth of 5-6 cm recommended by the current cardiopulmonary resuscitation guidelines is reliable for patients with different thoracic diameters.
Topics: Adult; Humans; Out-of-Hospital Cardiac Arrest; Prospective Studies; Cardiopulmonary Resuscitation; Thoracic Injuries; Fractures, Bone
PubMed: 36417655
DOI: 10.1590/1806-9282.20220822 -
Journal of Vascular Surgery Jul 2022Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend...
OBJECTIVE
Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management.
METHODS
We performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability.
RESULTS
A total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography.
CONCLUSIONS
Nonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.
Topics: Aneurysm, False; Aorta, Thoracic; Endovascular Procedures; Hematoma; Humans; Retrospective Studies; Thoracic Injuries; Time Factors; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 35314302
DOI: 10.1016/j.jvs.2022.03.012 -
Anaesthesiology Intensive Therapy 2022Penetrating thoracic trauma accounts for 20-25% of all deaths due to trauma in the first four decades of life. About 33% of deaths from thoracic trauma occur due to... (Review)
Review
Penetrating thoracic trauma accounts for 20-25% of all deaths due to trauma in the first four decades of life. About 33% of deaths from thoracic trauma occur due to penetrating trauma. In an autopsy study that enrolled 1178 trauma patients, 82% of the patients with tracheobronchial injuries died at the incidence site. In another study, 30% of those who could be transferred to the hospital died. This review aimed to revisit penetrating thoracic trauma with respect to complications and the strategies for airway management. While the risk of death in injuries with a sharp object is normally 1-8%, it reaches 25-28% when the cardiac box is included, and still, most of the patients are lost before they can come to the hospital. The consequences and management of penetrating thoracic trauma are mainly dependent on the extent of the injury to internal organs, as well as on the skill of the clinicians, airway obstruction, respiratory failure, and bleeding. Chest computed tomography (CT) is better than chest radiography in diagnosing the main bronchus or lobe/segment rupture. However, with the use of multi-channel multi-detector CT, the sensitivity of CT imaging has increased to 94% in the diagnosis of tracheobronchial injuries. While standard orotracheal intubation is sufficient in 75% of the patients, flexible bronchoscopy, intubation through the open wound or tracheostomy is required for airway provision in the rest. Clinical suspicion is the first diagnostic tool in a patient with penetrating airway trauma, and early treatment with multidisciplinary teamwork is life-saving.
Topics: Bronchoscopy; Humans; Intubation, Intratracheal; Thoracic Injuries; Tracheostomy; Wounds, Penetrating
PubMed: 36000693
DOI: 10.5114/ait.2022.118332