Posttraumatic empyema. Risk factor analysis.

Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

Chest injury is a common problem in patients sustaining blunt or penetrating trauma.1 Thoracic wounds account for 20-25% of all trauma deaths. Only 10-15% of all chest wounds require tube thoracostomy, whereas the remaining 85% can be managed with a closed tube thoracostomy.2 A major morbidity associated with this therapeutic device is empyema. The role of prophylactic antibiotics in reducing the incidence of this complication is controversial. Multiple factors contribute to the development of posttraumatic empyema. These factors include the conditions under which the tube is inserted (emergent or urgent), the mechanism of injury, retained hemothorax and ventilator care.3-8 The primary goal of prophylactic antibiotic use in injured patients requiring tube thoracostomy is to reduce the incidence of empyema and its associated morbidity. The primary benefit must be significant because of the risk of the emergence of resistant organisms with excessive use of antimicrobials. In addition, cost is a major concern in the current health care market. The above-mentioned concerns were the reasons for performing this study. Patients and methods This study is a randomized controlled trial. It took place over a 2-year period from June 2005 to June 2007. Patients aged 8-72 years with traumatic hemopneumothorax following blunt chest trauma and receiving chest tube placement were enrolled for the trial. Patients were excluded if they had penetrating chest trauma, needed to receive different antibiotics because of other injuries or had known immune-compromising disorders. The patients were classified as group-A and group-B randomly, with 54 cases out of 104 being assigned to group-A. The remainder (50 cases) was assigned to group-B. Since there are currently no clear-cut recommendations regarding antibiotic use in patients requiring tube thoracostomy to treat chest injury, there was no ethical deviation in this study. Group-A received 2gr of Cefazolin for the first 24 hours and group-B received a placebo. Patients were then followed daily for signs of empyema or pneumonia. Patients then received a telephone follow-up at 3 months after discharge evaluating for delayed evidence of empyema or pneumonia. In this study empyema is defined as a positive pleural culture or purulence within the thoracic space in conjunction with elevated white blood cell count and /or fever. Also, pneumonia was defined as evolving infiltrate on chest radiograph 24 hours after inserting the chest tube with either purulent sputum or a positive sputum culture. Our sample consisted of 75% males and 25% females with an average age of 39.6 years. The indication for tube placement was pneumothorax in 74 (69.2%), hemothorax in 20 (19.2%) and hemopneumothorax in 12 (11.5%). Totally 112 chest tubes were inserted. Eight of these patients received bilateral tubes. The average duration of tube placement was 6.8 days. Six patients developed pneumonia, 2 in group-A, 4 in group-B (p = 0.3). One patient from group-B developed empyema (p=0.48). Overall, this study revealed that prophylactic antibiotics did not significantly reduce the incidence of empyema or pneumonia in patients with blunt chest trauma. The use of prophylactic antibiotics for the prevention of empyema and pneumonia after tube thoracostomy remains a controversial issue in the trauma literature. While a number of studies show favorable effects, several reports have shown no benefit. 6-8 In our study the incidence of empyema was very low. Having prescribed prophylactic antibiotics to a large numbers of patients, we managed to prevent just a single empyema. We concluded that prophylactic antibiotic administration did not significantly reduce the incidence of empyema or pneumonia in these patients. Therefore, considering the emergence of resistant organisms and the cost and benefit, it seems that prophylactic antibiotics should not be administered in the management of chest tubes for blunt chest trauma; however, larger and more comprehensive studies should be performed to confirm this.

The natural history of retained hemothorax (RH), in particular factors contributing to the subsequent development of empyema, is not well known. The intent of our study was to establish the modern incidence of empyema among patients with trauma and RH and identify the independent predictors for development of this complication. An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of a thoracostomy tube within 24 hours of trauma admission, and subsequent development of RH was confirmed on computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors for the development of empyema. Among 328 patients with posttraumatic RH from the 20 participating centers, overall incidence of empyema was 26.8% (n = 88). On regression analysis, the presence of rib fractures (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.1; p = 0.006), Injury Severity Score of 25 or higher (adjusted OR, 2.4; 95% CI, 1.3-4.4; p = 0.005), and the need for any additional therapeutic intervention (adjusted OR, 28.8; 95% CI, 6.6-125.5; p < 0.001) were found to be independent predictors for the development of empyema for patients with posttraumatic RH. Patients with empyema also had a significantly longer adjusted intensive care unit stay (adjusted mean difference, 4.1; 95% CI, 1.3-6.9; p = 0.008) and hospital stay (adjusted mean difference, -7.9; 95% CI, -12.7 to -3.2; p = 0.01). Among patients with trauma and posttraumatic RH, the incidence of empyema was 26.8%. Independent predictors of empyema development after posttraumatic RH included the presence of rib fractures, Injury Severity Score of 25 or higher, and the need for additional interventions to evacuate retained blood from the thorax. Our findings highlight the need to minimize the risk associated with subsequent thoracic procedures among patients with critical illness and RH, through selection of the most optimal procedure for initial evacuation. Prognostic study, level III.

Introduction: Accidents represent a significant proportional of non-communicable disease in the current century, and chest injury is common. However, management and outcome of these injuries is poor in low resource setting like Tanzania. The aim of this study was to determine the prevalence and factors associated with mortality among chest injury patients at a tertiary level health facility in Tanzania. Method: A prospective Cross-Sectional study of chest injuries among trauma patients attended at Muhimbili National Hospital between September 2019 and February 2020. Results: A total of 282 trauma patients were seen, out of which 51/282 (18.1%) sustained chest injury. Road Traffic Crashes were the leading cause of chest injury 41/51 (80.4%). Majority 17/51 (33.3%) presented with lung contusion, followed by pneumohemothorax and rib fractures each 8/51 (15.7%). Most of the patients 27/51 (52.9%) were managed by tube thoracostomy and 42.1% conservatively. Mortality was 11/51 (21.6%). Independent factors associated with mortality were: Associated injuries (Odds Ratio (OR) 0.07, 95% CI 0.01 - 1.16, p = 0.02), Multimodal analgesia (Odds Ratio (OR) 0.22, 95% CI 0.05 - 0.98, p = 0.05), more than 24 hours to treatment (Odds Ratio (OR) 5.53, 95% CI 1.25 - 24.3, p = 0.02), Bilateral chest involvement (Odds Ratio (OR) 4.61, 95% CI 1.12 - 18.7, p = 0.02), and Invasive ventilation (Odds Ratio (OR) 31.5, 95% CI 4.47 - 53.8, p = 0.00). Conclusion: Chest injuries prevail significantly among trauma patients in Tanzania, mostly due to road traffic crashes. Injury preventive measures especially for road traffic crashes need to be reinforced, and establishment of chest injury management protocol in Tanzania.

Pain Management Guidelines for Blunt Thoracic Trauma Bruce Simon;James Cushman;Robert Barraco;Vivian Lane;Fred Luchette;Maurizio Miglietta;David Roccaforte;Ruth Spector; The Journal of Trauma: Injury, Infection, and Critical Care

From the Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France.TRAUMA is the leading cause of death among young people in developed countries. 1Because up to 80% of trauma deaths occur during the first 24 h after trauma, 1early resuscitation and rapid assessment of trauma lesions are of paramount importance to improving the prognosis. Among traumatic lesions, pulmonary contusion is frequent but has not been recognized as an independent prognosis factor. 2–4In very few cases, pulmonary contusion may lead to severe hypoxia and hypercarbia, which cannot be adequately controlled using conventional mechanical ventilation. Hypoxia and hypercarbia may have deleterious effects, such as enhancement of brain injury and development of circulatory shock. 5In the most severe cases, aggressive therapeutic methods, such as extracorporeal membrane oxygenation (ECMO), have been reported. 6At our institution, high-frequency jet ventilation (HFJV) has been used routinely for many years for the treatment of severe acute respiratory distress syndrome. 7,8We report a series of severe trauma patients with life-threatening pulmonary contusion successfully treated with HFJV when the conventional mechanical ventilation approach failed to provide appropriate gas exchange. The current data suggest that HFJV can be a life-saving technique in severely hypoxemic patients with bilateral pulmonary contusion.During a 6-yr period (1990–1996), 1,241 severe trauma patients were admitted to our Level 1 Trauma Centre. All trauma patients who received HFJV during the first 24 h after admission were identified and included in the study. One of these patients has been reported previously. 9The decision to perform HFJV was made by the senior anesthesiologist in charge of the emergency room because of the severity of pulmonary contusion. All patients fulfilled the following criteria: (1) partial pressure of oxygen (Pao2) less than 100 mmHg with an inspired fraction of oxygen (Fio2) of 100%; (2) progressive decrease in Pao2during the last hours without any trend to stabilization or improvement; (3) failure of further increases in positive end-expiratory pressure (PEEP) to improve Pao2or impossibility to increase PEEP because of hemodynamic consequences; (4) bilateral pulmonary contusion. An anesthesiologist and a nurse from the surgical intensive care unit initiated and adjusted HFJV in the emergency room. The decision to implement HFJV during the early period after trauma admission always was related to severe hypoxemia or circulatory shock. We did not include patients in whom HFJV was initiated because of systemic gas embolism related to pulmonary contusion. 10The following data were collected: age; sex; trauma lesions; administration of colloids, crystalloids, blood, and catecholamines; duration of stay in intensive care unit; and mortality. The following ventilatory parameters were recorded during conventional mechanical ventilation: ventilatory rate, tidal volume, and PEEP. The following parameters were measured at admission, during conventional mechanical ventilation, just before HFJV, 15–30 min after HFJV, and 24 h after admission: arterial pH, Pao2and partial pressure of carbon dioxide (Paco2), Pao2/Fio2ratio, mean arterial pressure measured using an indwelling radial or femoral artery catheter, and heart rate. The following indices were calculated: injury severity score (ISS), probability of survival according to the Trauma and Injury Severity Score (TRISS) methodology, 11and the Lung Injury Severity Score. (LIS) 12High-frequency jet ventilation was performed using an AMS 1000 ventilator (Acutronic Medical Systems AG, Hirzel, Switzerland). Rewarming and humidification of gases were provided by a HH-812 Jet humidifier (Acutronic Medical Systems). Additional conventional ventilation (low rate, 4–6 breaths/min; low tidal volume, 75–100 ml) was obtained using a CPU 1 ventilator (Ohmeda, Maurepas, France). Mean airway pressure was monitored continuously with a catheter located in the trachea 10 cm distal to the tip of the injector cannula, as previously reported. 7,8Data are mean ± SD. Comparison of several means was performed using repeated-measures analysis of variance. A P value less than 0.05 was considered significant.Over a 6-yr period, HFJV was used during the first 24 h after admission in nine patients (six male, three female) because of life-threatening hypoxemia related to pulmonary contusion. The incidence of life-threatening pulmonary contusion defined by this criteria was 0.73% (95% confidence interval, 0.26–1.20%). The mean age was 29 ± 15 yr (range, 8–58 yr), the mean ISS was 50 ± 17 (range, 20–75), the mean TRISS was 0.63 ± 0.36 (range, 0.08–0.96), and the mean LIS was 3.4 ± 0.3 (range, 3–4). These scores signify severe multisystem injuries. Associated head trauma was present in seven patients, abdominal trauma was present in four patients, spine trauma was present in four patients, and pelvic trauma in was present in two patients. All patients had severe thoracic trauma with bilateral pulmonary contusion. Chest radiography showed bilateral extensive and diffuse alveolar hyperdensities in all cases. Other traumatic thoracic lesions included hemothorax in three patients, pneumothorax in two patients, and aortic rupture in one patient. All patients underwent transesophageal echocardiography: mean left ventricular ejection fraction was 45 ± 29% (range, 10–71%), myocardial contusion was observed in five patients, and three patients had severe decrease in left ventricular ejection fraction (&lt; 30%). A search for a patent foramen ovale was performed in five patients; all results were negative. During the first 24-h period, fluid resuscitation consisted of 1.8 ± 1.3 l crystalloids, 3.7 ± 1.8 l colloids, 7 ± 8 units packed erythrocytes, 3 ± 3 units fresh frozen plasma, and 4 ± 5 platelet units. Catecholamines were administered in eight patients (epinephrine in three patients, norepinephrine in four patients, dopamine in five patients, and dobutamine in one patient). After HFJV, the dose of catecholamines was decreased in six patients and increased in two patients.Tracheal intubation was performed in all patients during the early resuscitation phase (delay, 51 ± 68 min after trauma). HFJV was initiated 7 ± 6 h after trauma. Table 1shows the evolution of the main hemodynamic, ventilatory, and blood gas parameters. Figure 1depicts the evolution of the Pao2/Fio2ratio during the first 24 h. The mean stay in the intensive care unit was 40 ± 38 days. Death occurred in four patients and was always related to severe brain injury. In the five surviving patients, HFJV was maintained for 7 ± 5 days (range, 3–15 days).We report that HFJV dramatically increased Pao2in a group of trauma patients with life-threatening hypoxemia related to bilateral pulmonary contusion. Despite severe pulmonary contusion, death always occurred because of brain injury and not because of pulmonary contusion, and weaning of HFJV was obtained successfully in all the remaining patients. These results confirm previous reports that suggest that HFJV can be effective as a rescue therapy for refractory acute lung dysfunction. 13,14The current study cannot definitely assess the mechanisms involved in the beneficial effect of HFJV. Because of the emergency and critical conditions, a pulmonary computed tomography scan could not be obtained in most of these patients at the early phase. Nevertheless, thoracic radiography highly suggested that diffuse pulmonary contusion occurred, and thus that alveolar recruitment induced by HFJV was likely the main mechanism responsible for the marked increase in Pao2observed in our patients. HFJV is known to induce an increase in functional residual capacity by trapping intrapulmonary gases because of incomplete exhalation during the short expiratory time (auto-PEEP effect). Two other mechanisms should be considered. First, closure of a patent foramen ovale may have reduced hypoxemia, as previously reported. 15However, it should be noted that an increase in pulmonary artery pressure (potentially leading to right-to-left intracardiac shunt) usually is not observed at the very early stage of pulmonary contusion and that we failed to find evidence of any patent foramen ovale using transesophageal echocardiography in five of these patients. Second, an improvement in hemodynamic conditions may have contributed to the HFJV-induced increase in Pao2. This last effect can be complex because an increase in cardiac output can decrease Pao2through capillary recruitment but also can increase Pao2through an increase in mixed venous oxygen saturation. In patients with septic shock, Fusciardi et al. 16have shown that mean arterial pressure and cardiac output are higher during HFJV than during conventional mechanical ventilation when compared at the same airway pressure and Paco2. However, this hemodynamic improvement was associated with a small deterioration in arterial oxygenation. 16Because the mean PEEP value was not high in our study, one can argue that a marked increase in PEEP might have induced an effect similar to that observed with HFJV. In our patients, such an increase in PEEP could not be applied without marked alteration in hemodynamic conditions. Associated right ventricle contusion is likely to explain that our patients poorly tolerated any further increase in intrathoracic pressure. 9At an identical level of mean airway pressure, HFJV is better hemodynamically tolerated than PEEP in shocked patients. 17It should be pointed out that high PEEP is associated with high peak inspiratory pressure that can be harmful in patients with pulmonary contusion because it increases pulmonary edema, 18causes barotrauma through alveolar rupture, and facilitates pulmonary venous gas embolism. 10It has been demonstrated recently that reducing tidal volume during mechanical ventilation in ARDS decreases mortality. 19High PEEP and low tidal volume induce hypercapnia that is deleterious in patients with head trauma. As shown in table 1, HFJV enabled control of Paco2and Pao2in patients with severe life-threatening pulmonary contusion. Moreover, the fluid loading required to overcome the hemodynamic effects of PEEP on venous return also may increase extravascular lung water.In conclusion, in rare cases of severe bilateral pulmonary contusion refractory to conventional mechanical ventilation, HFJV may be a life-saving procedure. Because of the rarity of these cases, there is a low possibility that a randomized trial could ever be conducted. Therefore, traumatologists, intensivists, and anesthesiologists should be aware of this therapeutic possibility and should try HFJV before irreversible consequences of hypoxemia or hypercarbia occur in these severe trauma patients. Moreover, HFJV is probably a more simple procedure than ECMO, which sometimes has been used in such patients 6but usually is contraindicated in severe head trauma.

Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( β = -1.58; 95% CI, -2.52 to -0.75). Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. Therapeutic/Care Management; Level III.

To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces

BACKGROUND AND OBJECTIVESIn Saudi Arabia (SA), injuries are the second leading cause of death; however, little is known about their frequencies and outcomes. Trauma registries play a major role in measuring the burden on population health. This study aims to describe the population of the only hospital-based trauma registry in the country and highlight challenges and potential opportunities to improve trauma data collection and research in SA.DESIGN AND SETTINGSUsing data between 2001 and 2010, this retrospective study included patients from a large trauma center in Riyadh, SA.PATIENTS AND METHODSA staff nurse utilized a structured checklist to gather information on patients’ demographic, physiologic, anatomic, and outcome variables. Basic descriptive statistics by age group (≤14 vs >14 years) were calculated, and differences were assessed using student t and chi-square tests. In addition, the mechanism of injury and the frequency of missing data were evaluated.RESULTS10 847 patients from the trauma registry were included. Over 9% of all patients died either before or after being treated at the hospital. Patients who were older than 14 years of age (more likely to be male) sustained traffic-related injuries and died in the hospital as compared to patients who were younger than or equal to years of age. Deceased patients were severely injured as measured by injury severity score and Glasgow Coma Scale (P<.001). Overall, the most frequent type of injury was related to traffic (52.0%), followed by falls (23.4%). Missing values were mostly prevalent in traffic-related variables, such as seatbelt use (70.2%).CONCLUSIONThis registry is a key step toward addressing the burden of injuries in SA. Improved injury classification using the International Classification of Disease-external cause codes may improve the quality of the registry and allow comparison with other populations. Most importantly, injury prevention in SA requires further investment in data collection and research to improve outcomes.

Traumatic chest injury is one the most important factors for total morbidity and mortality in traumatized emergency patients (1). Chest trauma is the cause of 20% to 25% of the trauma-related deaths per year in the United States and is the leading cause of death in the first four decades of life (2). Traumatic chest injuries often occur in combination with other severe injuries, such as head, brain, extremity and abdominal injuries (3). Traumatic chest trauma can occur after car and motor accident, assaults, falls and explosive blasts via a variety of different mechanisms. Overall, car and motor accidents account for 70% to 80% of all thoracic injuries (4). Traumatic chest lesion can lead to conditions like pulmonary contusion pneumothorax, flail chest, bronchopleural fistula, and tracheobronchial rupture. One of the most frequent intrathoracic injuries is lung contusion that results from blunt chest trauma. Particularly, in patients with multiple traumas, severe blunt chest injuries and especially pulmonary contusions may deteriorate the patients’ outcome due to increased morbidity and mortality. Parenchymal lung injuries, such as pulmonary contusion, may require support of oxygenation and ventilation through mechanical ventilation strategies. The majority of traumatic chest injuries can be treated with careful observation or minor surgery such as tube thoracostomy. Among the patients of traumatic chest injuries 12% to 15% of them will require thoracotomy. In patients with impaired gas exchange, endotracheal intubation and mechanical ventilation are essential. Moreover, further pulmonary complications such as acute respiratory distress syndrome (ARDS) and respiratory failure can be prevented by early fixation of concomitant long-bone fractures. Ventilation in traumatic chest patients may remain a challenge due to complexity in obtaining balance between sufficient ventilation and prevention of further harm to the lungs. The goal of ventilation in this condition is protective lung ventilation with low FiO2, plateau pressure, and using reduced tidal volumes to protect the lungs from further injury (1). The tidal volume should be limited to less than 6 mL/kg of ideal body weight and plateau pressure to 12 cm H2O is required, invasive positive-pressure ventilation (IPPV) should be considered.

Computed tomography-detected hemothorax after blunt chest trauma: Does everyone need an intervention? A retrospective analysis.

The worldwide escalation in the volume of suicide terrorist bombing attacks warrants special attention to the specific pattern of injury associated with such attacks. The goal of this study was to characterize thoracic injuries inflicted by terrorist-related explosions and compare pattern of injury to penetrating and blunt thoracic trauma. Prospectively collected database of patients with chest injury who were admitted to Hadassah Hospital Level I trauma centre, in Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into three groups according to the mechanism of injury: terrorist explosions (n = 55), gunshot wounds (GSW; n = 78), and blunt trauma (n = 747). There were many female victims after suicide bombing attacks (49.1%) compared with GSW (21.8%) and blunt trauma (24.6%; p = 0.009). The number of body regions injured was significantly higher in the terror group compared with the GSW and blunt groups (median, 4, 2, and 3, respectively, p < 0.0001). The pattern of chest injury after suicide bombing attacks was caused by a unique combination of the effects of the blast wave and penetrating shrapnel. More than half (52.7%) of the terror victims suffered from lung contusion and 25 (45.5%) required tube thoracostomy. Five patients (9.1%) underwent thoracotomy for lung lacerations (n = 3), injury to great vessels (n = 2), cardiac lacerations (n = 1), and esophageal injury (n = 1). Penetrating shrapnel was the mechanism of injury in all these cases. Injury inflicted by terrorist bombings causes a unique pattern of thoracic wounds. Victims are exposed to a combination of lung injury caused by the blast wave and penetrating injury caused by metallic objects.

Pulmonary contusions in the elderly after blunt trauma: incidence and outcomes