Blunt Thoracic Injury Research Articles

Occupant- and collision-related risk factors for blunt thoracic aorta injury.

Blunt thoracic aortic injury (BAI) is a rare and highly lethal injury. We sought to identify occupant and collision characteristics associated with motor vehicle collision (MVC)-related BAI. The 1995 to 2000 National Automotive Sampling System data files were used. The National Automotive Sampling System is a national probability sample of passenger vehicles involved in police-reported tow-away MVCs. The risk of BAI was calculated according to specific occupant (e.g., age, seat belt use) and collision (e.g., delta-V [estimated change in velocity], vehicular intrusion) characteristics. The association between BAI and these characteristics was calculated using risk ratios (RRs) and associated 95% confidence intervals (CIs). Specific occupant and collision characteristics demonstrated independent association with BAI. Occupant characteristics included age >or= 60 (RR, 3.6; 95% CI, 2.5-5.2), seat belt use (RR, 0.3; 95% CI, 0.2-0.5), and being a front-seat occupant (RR, 3.1; 95% CI, 1.5-6.3). Frontal and near-side MVCs were associated with an increased risk (RR, 3.1; 95% CI, 1.9-5.1; and RR, 4.3; 95% CI, 2.6-7.2, respectively) relative to other collision types. Collisions with a delta-V >or= 40 km/h (RR, 3.8; 95% CI, 2.6-5.6) or that produce extensive vehicle crush (>or= 40 cm) (RR, 4.1; 95% CI, 2.7-6.3) or intrusion (>or= 15 cm) (RR, 5.0; 95% CI, 3.5-7.3) also increase the risk of BAI. The risk factors for BAI identified in this study support generally accepted etiologic mechanisms for this injury.

Incidence and Characteristics of Motor Vehicle Collision–Related Blunt Thoracic Aortic Injury According to Age

Motor vehicle collision-related blunt thoracic aorta injury (BAI) is rare and highly lethal. Vascular disease as related to advancing age potentially subjects older adults to increased risk of BAI; the mechanisms associated with such injuries may be different as compared with younger adults. The goal of the present study is to test this hypothesis using population-based data. The 1995 to 1999 National Automotive Sampling System data files were used. The National Automotive Sampling System is a national probability sample of passenger vehicles involved in police-reported tow-away crashes. BAI was defined according to the Abbreviated Injury Scale codes. Among those with BAI, information on occupant (age, seating position, restraint use), collision (collision type, delta-V, vehicle intrusion), and outcome characteristics were obtained and compared according to age. The overall incidence of BAI was 6.8 per 10,000 occupants and there was a steady increase in the BAI rate for advancing decades of life. The proportion of occupants with BAI who die at the scene of the collision is relatively consistent across all age groups ( approximately 85%). Among those who survive to receive medical care, ultimate survival is lowest among those aged 60 and older. Near-side collisions were responsible for more BAI among older adults than other age groups (50% vs. 20.6%, p < or = 0.05). Older adults sustained BAI in collisions with lower delta-V values compared with younger persons (p < or = 0.05). Older adults have the highest rate of motor vehicle collision-related BAI, and their injuries tend to occur in less severe collisions. A high level of suspicion for BAI among older adults should not be reserved for high-energy collisions only.

Endovascular stent grafting for the treatment of blunt thoracic aortic injury.

Recent advances of endovascular stent-grafting (ESG) provide a new therapeutic option with minimum surgical damage for blunt aortic injury (BAI) during its acute phase. To clarify the effectiveness of ESG for BAI, a prospective clinical study at a university hospital was conducted. All patients with blunt thoracic injury underwent thoracic contrast-enhanced computed tomographic (CT) scan. Six patients age 48.8 +/- 19.8 years, with Injury Severity Scores of 35.8 +/- 8.1, and with BAI were treated according to our protocol. The stent-graft covered by woven Dacron was placed at the injury site. Endoleakage was then checked by aortography and CT scan was again performed once a day on days 7 through 14. All patients had injury of the aortic isthmus. ESG placement was performed within 8 hours after injury except in one (48 hours). The operating time was 159.5 +/- 21.1 minutes and bleeding volume was 105 +/- 26.6 mL. No endoleakage was found. Repeat CT scan revealed disappearance of hematoma. All patients except one had an event-free clinical course. One patient died because of rupture of the ascending aorta on day 6; however, autopsy revealed evidence of the healing process at the injury site sealed by ESG. An ESG is a valid therapeutic option with minimal surgical invasion for patients with acute-phase aortic injury.

Blunt thoracic and abdominal vascular trauma and organ injury caused by road traffic accident.

To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.

Appraisal of Early Evaluation of Blunt Chest Trauma: Development of a Standardized Scoring System for Initial Clinical Decision Making

Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.

Tracheobronchial injuries after blunt chest trauma in children—Hidden pathology

Background: Blunt thoracic injuries in children are unique because the pliability of the chest wall allows transmission of massive external force directly into the mediastinum. Children presenting after blunt chest trauma may have complete disruption of the airway with little external sign of injury. Without prompt diagnosis and appropriate treatment, the risk for progressive respiratory failure is high. Methods: Four children with tracheobronchial injuries were referred to a pediatric trauma center from 1994 to 1997. All children, age 18 months to 13 years, suffered unusual crush injuries. All diagnoses were based on unresolved pneumothorax or pneumomediastinum. Results: Bronchoscopy identified the location of injury as posterior trachea (n = 1) and right mainstem bronchus (n = 2). A tertiary bronchial injury (n = 1) was missed by initial tracheogram and subsequent bronchoscopy but identified during surgical exploration. All children survived after thoracotomy and primary repair of the injury. Conclusions: Tracheobronchial disruption is a rare, life-threatening injury. Suspicion should be high when pneumomediastinum and pneumothorax are refractory to adequate pleural drainage. Flexible bronchoscopy with intubation distal to the injury may be necessary to prevent loss of the airway. Advance preparation should include setups for bronchoscopy, thoracotomy, and cardiopulmonary bypass. Patient survival depends on preparation and prompt surgical intervention.

Blunt thoracic injury

Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.

Computed tomography of the chest in blunt thoracic trauma: results of a prospective study.

Computed tomography of the chest (CTC) is more sensitive than conventional roentgenography at detecting blunt thoracic injuries. Its effect on subsequent therapy remains incompletely characterized. Nine criteria believed to represent the presence of, or the potential for, significant thoracic injuries were defined, and patients were followed prospectively. Forty consecutive patients had CTC after initial evaluation. Physiologic and anatomic findings were compared, and the effect of CTC on therapy was analyzed. CTC detected 76 injuries not found on plain roentgenograms, and plain roentgenograms detected 25 injuries not visible on CTC scans. Six patients had therapy changes based on CTC findings, five of which involved chest tube modification. The percentage of pulmonary contusion did not predict the need for mechanical ventilation but did correlate with physiologic contusion. Blunt thoracic injuries detected by CTC infrequently require immediate therapy. If immediate therapy is needed, findings will be visible on plain roentgenograms or on clinical exam. Routine CTC in blunt trauma is not recommended but may be helpful in selected cases.

Diaphragmatic injuries--classification, diagnosis and therapy

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.

Fractures of the Proximal Ulna in Dogs

SummaryIn a retrospective study of fractures of the proximal ulna in dogs, 22 cases were identified over a 12-year period. Follow-up data was available for 13 dogs. Fractures of the proximal ulna were often comminuted, and most commonly had an intra-articular component affecting the ulnaro-humeral joint. Common causes included: motor vehicle trauma and falls from a height. Blunt thoracic trauma and additional orthopaedic injuries were often seen with the more severe types of fractures.Healing of intra-articular proximal ulnar fractures usually occurred after anatomical reconstruction and rigid internal fixation. Secondary osteoarthritis was minimal. The pin and tension band technique gave satisfactory results for simple non-articular fractures of the olecranon, but for intra-articular fractures this fixation method was associated with a greater incidence of complications such as: implant breakage, delayed union and infection. Implant loosening or breakage and delayed union were not observed, when fracture fixation with bone plates placed on the caudal or lateral aspects of the ulna was performed. Localized infection associated with a bone plate was identified in one of 10 patients and plate removal was carried out after the fracture had healed.Fractures of the proximal ulna in 13 dogs were frequently intra-articular and comminuted. Most fractures stabilized with tension band fixation or a small bone plate on the caudal surface of the ulna healed with minimal secondary osteoarthritis. However, complications with tension band fixation were common.

Bilateral Diffuse Infiltrate Masking a Cavity After Blunt Chest Trauma

A 19-year-old man was refered to our hospital for chest trauma. He had suffered a blunt thoracic injury from a motor vehicle accident. He did not smoke. His medical history was irrelevant. He complained of dyspnea as well as left-sided chest pain. Physical examination on admission revealed a temperature of 36.5°C, a respiratory rate of 38 breaths per min, and a pulse rate of 98 beats per min. The blood pressure was 100/70 mm Hg. Inspiratory crackles were heard over the left lung. The remainder of the physical examination findings were normal. Laboratory studies disclosed a hematocrit of 33.0%. The white cell count was 98×109/L with 68% neutrophils, 19% lymphocytes, 7.8% monocytes, and 2.1% eosinophils. The erythrocyte sedimentation rate was elevated to 60 mm/h. A specimen of arterial blood, drawn while the patient was breathing room air, showed that the Po2 was 42 mm Hg, PCO2 40.8 mm Hg, and pH 7.30. The remainder of the laboratory findings were unremarkable.

Mortality and truncal injury: The pediatric perspective

To determine the extent and consequences of major truncal injury in children, we analyzed data collected prospectively by the National Pediatric Trauma Registry (NPTR) from 1985 to 1991. Of the 25,301 patients entered into the study, 1,553 (6%) had thoracic injuries (T); 2,047 (8%) had abdominal injuries (A). Blunt mechanisms predominated for both groups (86% T, 83% A), with the automobile being the most frequent blunt agent (74% T, 59% A); gunshot wounds were responsible for the majority of penetrating injuries (60% T, 56% A). Fifteen percent (195) of those with blunt thoracic injuries died; however, in only 14% of these cases (27) was thoracic injury the cause of death. Fourteen percent (33) of those with penetrating thoracic injuries died, with thoracic injury the cause of death in 97% of these cases (32). Only 9% (161) of those with blunt abdominal injuries diet; in 22% (35) abdominal injury was the cause of death. Likewise, only 6% (15) of those with penetrating abdominal injuries died, but abdominal injury was the cause of death in 67% (10). The pleural space, lung, and ribs were the most frequently damaged thoracic organs; with the exception of lung contusion, injuries to these structures were associated with fatality rates in excess of 50%. The liver, spleen, kidneys, and gastrointestinal tract were the most frequently damaged abdominal organs; injuries to these structures were associated with fatality rates of 15% or less, except for injuries involving major blood vessels. These data establish the facts that (1) whereas abdominal injuries are 30% more common than thoracic injuries, they are 20% less likely to be associated with death, and (2) thoracic injury now exceeds abdominal injury as a cause of death, second only to head injury in its lethal potential. Moreover, this study confirms the findings of others that serious thoracic injury is a marker of injury severity, and suggests that facility with management of thoracic as well as abdominal injury is vital to optimal outcome in childhood trauma.

Computed tomography in the diagnosis of blunt thoracic injury

Computed tomography (CT) is an important diagnostic modality in the evaluation of blunt head and abdominal injuries, but it has not been routinely used to evaluate blunt chest trauma. One hundred seventy stable patients with blunt thoracic trauma were evaluated with chest x-ray (CXR), and subsequently by CT. Of a total of 131 fractures, 53% were identified on initial CXR, 39% on CT, and 26% were not seen on either study. Twenty-one pneumothoraces were seen on CT but not on CXR. Chest tubes were placed in 8 patients and 12 patients were observed without incident. One hemothorax identified by CT scan alone required treatment. Four of 6 diaphragmatic injuries were seen on CT and 2 on CXR. Parenchymal abnormalities were apparent in 189 lung fields on CT and in 66 lung fields on CXR. Most represented atelectasis and did not require treatment. Altogether, CT scanning resulted in changes in management for 11 patients (6%). Although CXR is less sensitive in detecting parenchymal and pleural injuries than CT, the majority of the injuries identified by CT alone are minor and require no treatment. CXR remains the primary modality for diagnostic evaluation of blunt thoracic trauma.

ULTRASOUND IN BLUNT ABDOMINAL AND THORACIC TRAUMA

Between July 1989 and June 1991, 312 patients with blunt thoracic or abdominal injuries were examined prospectively. Sonographic examination was performed by surgeons in the emergency room using a mobile ultrasound unit. In 113 (36.2%) cases pathologic findings were demonstrated sonographically. These included 47 cases of hemothorax, 11 pericardial effusions, 52 cases of intra-abdominal fluid, 24 lesions of intra-abdominal organs, and 10 cases of retroperitoneal hematoma. Physical examination findings were positive in 96 (30.8%), negative in 63 (20.2%), and equivocal in 153 (49.0%). Two hundred thirty-nine patients had between one and eight injuries in addition to the blunt abdominal or thoracic trauma. These patients had an average Injury Severity Score (ISS) of 19.9 (range, 1 to 75). The 73 patients with isolated blunt trauma of the thorax or abdomen had an ISS of 4.9 (range, 0-25). None of the 66 patients (21.2%) with positive clinical findings and negative sonographic examination results had to be operated on later in the course of treatment, while 5 (36%) of 14 patients (4.5%) with negative physical examination findings and positive sonographic findings had to undergo surgery. The sensitivity for the demonstration of intra-abdominal fluid and organ lesions was 98.1% and 41.4%, respectively. The overall sensitivity and specificity of the ultrasonic examination were 90.0% and 99.5%, respectively.

Perioperative cardiovascular complications associated with blunt thoracic trauma

The purpose of this study was to examine the frequency and importance of intraoperative mortality, arrhythmias and hypotension in the presence of thoracic trauma and to determine the effect of myocardial contusion on these perioperative complications. Over a two-year period patients with evidence of blunt thoracic injury who required surgery within 24 hr of admission were studied. The anaesthetist filled in a questionnaire on intraoperative events. Patients were also studied for the presence of myocardial injury with radionuclide angiography (RNA), at autopsy or at thoracotomy. Two hundred and one patients were studied. The intraoperative and overall mortality was 7.9% and 22.9% respectively. Of the operating room survivors the incidence of intraoperative arrhythmias and hypotension was 3.8% and 26.5% respectively. Only 5.9% of patients had a suspected or confirmed myocardial contusion. Patients were divided into two groups, those without myocardial injury were designated Group I, while those with myocardial contusion were designated Group II. The Group II patients had a greater severity of injury and intraoperative mortality (54.4%) than those in Group I (4.6%) P < 0.05. Intraoperative deaths were attributed to, with one exception, non-cardiac causes. There were no differences in the incidences of arrhythmias and hypotension between patients with-or without myocardial injury surviving the operating room. All patients with blunt thoracic injury may develop intraoperative arrhythmias or hypotension.

Anaesthetic management of acute blunt thoracic trauma

Sunnybrook Health Science Centre is an adult regional trauma unit serving metropolitan Toronto and environs. We undertook a two-year retrospective review of patients admitted to our institution with blunt thoracic trauma. Three hundred and thirty-three patients with blunt trauma and an injury severity score (ISS) greater than 17 required emergency surgery. Of these, 208 had blunt thoracic injuries while 125 did not have chest injuries. Both groups were similar with respect to age but patients with thoracic trauma had a greater ISS. (P less than 0.05) and greater intraoperative mortality (P less than 0.01). The aetiology of the intraoperative deaths with one exception was exsanguination. Emergency thoracotomy or sternotomy indicated a poor prognosis with a mortality rate of 80%. The most common intraoperative problem was an elevated airway pressure. Awake intubation was undertaken in 77.5% of patients requiring anaesthesia and surgery because of the potentially compromised airways and difficult intubations due to the nature of the associated injuries. Finally, 74% of patients undergoing urgent surgery required mechanical postoperative ventilation. The presence of blunt chest trauma should be considered a marker of the severity of injury sustained by the patient.

Left Atrial Rupture Following Blunt Thoracic Injury: Case Report

A 22-year-old man presented with intermittent tachycardia and left-sided flail chest after an automobile accident. Initially his condition was stable, but 7 hours after the injury cardiac asystole appeared. Cardiopulmonary resuscitation was immediately begun and operation was performed. A rupture of the left atrium was successfully repaired without cardiopulmonary bypass.

Péricardite constrictive posttraumatique à évolution rapide

A case is reported of a 46-years-old male patient who sustained a blunt thoracic injury with an anterior flail chest, and right haemopneumothorax. He was intubated and ventilated because of acute respiratory failure. There were initially no signs suggesting any myocardial injury. It was not before day 20 that the electrocardiogram showed a QS wave in leads V 2 and V 3. The hypothesis of an antero-septal myocardial infarct was not confirmed by echocardiography, which only revealed slight thickening of the posterior pericardium. From day 50 on, the patient had tachycardia, raised jugular venous pressure, and effort dyspnoea. Echocardiography (day 59) showed an anterior and posterior pericardial effusion (about 500 ml), marked pericardial thickening, and inferior vena caval collapse during inspiration, with normal myocardial wall movements. Drainage pericardiocentesis was therefore carried out, followed by, four days later, a pericardiectomy. A small ecchymosis was found on the anterior aspect of the right ventricle. The pericardium was thickened, fibrous, hyperhaemic, and partly stuck to the epicardium. Eight months later, echocardiography showed that the posterior pericardium remained thickened, and there was a very small residual effusion. Movements of the septum had returned to normal.

Acute Aortic Valvular Incompetence Following Blunt Thoracic Deceleration Injury

Blunt trauma leading to aortic valvular incompetence is rarely encountered, with 27 cases reported to date. All cusps and commissures are involved to a similar degree. Treatment includes either reattachment of cusps to the annulus (80% recurrence of incompetence) or valvular replacement (no recurrence). Valve replacement is the treatment of choice for these patients.

Cardiac contusion from blunt thoracic injury

Cardiac contusion from blunt thoracic injury