Injuries to the chest wall are common after blunt thoracic trauma, which can cause injury to the ribcage and intrathoracic structures. Such trauma can result in a spectrum of injuries, ranging from minor injuries such as an isolated rib fracture to extensive injuries such as multiple rib fractures/flail segments with underlying lung or intrathoracic injury. The primary focus of this article will be on the assessment and treatment of injuries of the bony chest wall, with an emphasis on flail chest and multiple rib fractures. Patient evaluation, treatment, and outcomes differ depending on the severity of injury. The use of CT scans has become routine in the diagnosis and evaluation of injury severity. Treatment options include both nonsurgical care (analgesia, regional anesthetic techniques, and mechanical ventilation) and surgical fixation of the chest wall. While there has been notable interest in surgical fixation of flail chest injuries over the past two decades, there remains controversy regarding the potential benefits of surgery and the indications for surgical management. However, it is clear that patients with flail chest injuries are best managed by a multidisciplinary team, including collaboration between orthopaedic and trauma surgery.

Flail chest resulting from multiple rib fractures after cardiopulmonary resuscitation (CPR) can cause pain and respiratory distress. In this case report, we describe the use of bilateral parasternal intercostal block catheters in a patient who was unable to breathe adequately and could not be extubated due to rib fractures after CPR. The patient received analgesia via the parasternal catheter for 11 days and was discharged on the 17th day. This report highlights the importance of successful pain management through continuous analgesia via a continuous parasternal intercostal block catheter, thereby reducing the time to extubation and decreasing respiratory complications.

Background/Objectives: Acute respiratory distress syndrome (ARDS) represents a critical complication in polytrauma patients, characterized by diffuse lung inflammation and bilateral pulmonary infiltrates with mortality rates reaching 45% in intensive care units (ICU). The heterogeneous nature of ARDS and complex clinical presentation in severely injured patients poses substantial diagnostic challenges, necessitating early prediction tools to guide timely interventions. Machine learning (ML) algorithms have emerged as promising approaches for clinical decision support, demonstrating superior performance compared to traditional scoring systems in capturing complex patterns within high-dimensional medical data. Based on the identified research gaps in early ARDS prediction for polytrauma populations, our study aimed to: (i) develop a balanced random forest (BRF) ML model for early ARDS prediction in critically ill polytrauma patients, (ii) identify the most predictive clinical features using ANOVA-based feature selection, and (iii) evaluate model performance using comprehensive metrics addressing class imbalance challenges. Methods: This retrospective cohort study analyzed 407 polytrauma patients admitted to the ICU of the Center of Traumatology and Major Burns of Ben Arous, Tunisia, between 2017 and 2021. We implemented a comprehensive ML pipeline that incorporates Tomek Links undersampling, ANOVA F-test feature selection for the top 10 predictive variables, and SMOTE oversampling with a conservative sampling rate of 0.3. The BRF classifier was trained with class weighting and evaluated using stratified 5-fold cross-validation. Performance metrics included AUROC, PR-AUC, sensitivity, specificity, F1-score, and Matthews correlation coefficient. Results: Among 407 patients, 43 developed ARDS according to the Berlin definition, representing a 10.57% incidence. The BRF model demonstrated exceptional predictive performance with an AUROC of 0.98, a sensitivity of 0.91, a specificity of 0.80, an F1-score of 0.84, and an MCC of 0.70. Precision-recall AUC reached 0.86, demonstrating robust performance despite class imbalance. During stratified cross-validation, AUROC values ranged from 0.93 to 0.99 across folds, indicating consistent model stability. The top 10 selected features included procalcitonin, PaO2 at ICU admission, 24-h pH, massive transfusion, total fluid resuscitation, presence of pneumothorax, alveolar hemorrhage, pulmonary contusion, hemothorax, and flail chest injury. Conclusions: Our BRF model provides a robust, clinically applicable tool for early prediction of ARDS in polytrauma patients using readily available clinical parameters. The comprehensive two-step resampling approach, combined with ANOVA-based feature selection, successfully addressed class imbalance while maintaining high predictive accuracy. These findings support integrating ML approaches into critical care decision-making to improve patient outcomes and resource allocation. External validation in diverse populations remains essential for confirming generalizability and clinical implementation.

Dyspnoea remains a common cause of emergency admissions in sub-Saharan Africa, where diagnostic delays are compounded by limited access to advanced imaging modalities. Point-of-care ultrasound (POCUS) is increasingly recognised as an essential tool for the rapid bedside evaluation of cardio-pulmonary disorders. We report the case of a 71-year-old man admitted to the Essos Hospital Centre emergency department with acute dyspnoea, fever, and hypoxaemia. Cardiac POCUS revealed right ventricular dilatation with paradoxical interventricular septal motion, while lung ultrasound demonstrated bilateral pleural effusions and a B-profile, immediately suggesting a dual pathology: acute pulmonary embolism and bilateral pleuro-pneumonia. Thoracic CT angiography confirmed a segmental embolus in the left lower lobe associated with a pleuro-pneumonia. Early initiation of anticoagulation and targeted antibiotic therapy, guided by POCUS findings, resulted in rapid clinical improvement. This case highlights the major diagnostic value of integrating cardiac and lung POCUS into emergency assessment, particularly in resource-limited African settings where imaging delays may compromise outcomes.

Surgical stabilization of rib fractures (SSRF) is increasingly performed. Nationwide data comparing its outcomes with nonoperative management (NOM) and defining the best timing for SSRF are scarce. We analyzed data from the American College of Surgeons Trauma Quality Improvement Program, 2017-2021. Adults with three or more blunt rib fractures and no major extrathoracic injury were included. Surgical fixation was compared with risk-weighted NOM using inverse probability of treatment weighting. Primary outcome was in-hospital mortality. Secondary outcomes were hospital and intensive care length of stay, ventilator duration, ventilator-free days, acute respiratory distress syndrome, and ventilator-associated pneumonia. Subgroup analyses examined flail chest and the impact of timing of fixation, which was modeled as a continuous exposure with a generalized additive spline; its discriminatory performance was evaluated with receiver-operating-characteristic curve analysis to calculate the Youden's index. A total of 3,806 patients underwent SSRF, and 3,753 weighted controls received NOM. After weighting, an association of SSRF with lower mortality (1.5% vs. 2.7%, p < 0.001) but longer hospital (median, 10 vs. 5 days) and intensive care stays (5 vs. 3 days, both p < 0.001) were observed. In the flail chest subgroup, SSRF was associated with a mortality of 4.2% compared with 10.1% with NOM ( p = 0.002). In the nonflail group, mortality was 1.3% after SSRF versus 2.0% in NOM ( p = 0.003). Early SSRF within 82 hours had similar mortality to delayed fixation (1.6% vs. 1.4%, p = 0.647). However, early SSRF was associated with lower rates of acute respiratory distress syndrome (0.5% vs. 1.5%), ventilator-associated pneumonia (0.9% vs. 2.3%), and shorter hospital stays compared with delayed SSRF. Nationwide data demonstrated that SSRF is associated with higher survival, particularly in patients with flail chest, at the cost of increased resource utilization. Surgical stabilization of rib fractures performed within 82 hours is associated with higher survival, lower pulmonary morbidity, and additional resource utilization. Therapeutic/Care Management; Level III.

BackgroundA traumatic flail chest impairs chest wall mechanics and gas exchange. Bedside indices that integrate lung mechanics (driving pressure and dynamic compliance) with perfusion efficiency (dead-space surrogates) may guide ventilator titration more effectively than oxygenation alone.ObjectiveTo determine whether dead-space burden, driving pressure, and dynamic compliance are associated with intensive care unit (ICU) mortality and other clinically relevant outcomes (ventilator-free days to day 28 (VFD-28), ICU length of stay (LOS), barotrauma, and ICU-acquired pneumonia) in invasively ventilated adults with a flail chest.MethodsWe conducted a retrospective cohort study in the Anesthesia Department of Lady Reading Hospital (Peshawar, Pakistan). Consecutive adults with flail chest admitted between March 1, 2024, and February 28, 2025, were included. Exposures were time-weighted mechanics (driving pressure and dynamic compliance) and dead-space measures, including alveolar dead-space fraction (AVDSf) when available or ventilatory ratio (VR) otherwise. The primary outcome was ICU mortality. Secondary outcomes were VFD-28, ICU LOS, barotrauma, and ICU-acquired pneumonia. The pre-specified models included multivariable logistic, negative binomial, quasi-Poisson, Fine-Gray competing risk, and time-updated mixed-effects analyses.ResultsOf the 318 patients screened, 272 (85.5%) met the inclusion criteria. High dead space (AVDSf ≥ 0.25 or VR ≥ 1.5) occurred in 134/272 (49.3%) patients. ICU mortality was 54/272 (19.9%) overall and higher with high versus low dead space (40/134, 29.9% vs. 14/138, 10.1%; risk ratio = 2.97; 95% CI = 1.73-5.09; χ² (1) = 16.59; P < 0.001). In the adjusted models, high dead space remained associated with mortality (adjusted odds ratio (aOR) = 2.21; 95% CI = 1.24-3.93; z = 2.69; P = 0.007). Each 1-cmH₂O increase in driving pressure increased mortality risk (aOR = 1.05; 95% CI = 1.01-1.09; z = 2.51; P = 0.012), whereas each 10-mL/cmH₂O increase in dynamic compliance was protective (aOR = 0.82; 95% CI = 0.70-0.96; z = −2.46; P = 0.014). High dead space was associated with lower VFD-28 (adjusted rate ratio = 0.83; 95% CI = 0.71-0.98; z = −2.27; P = 0.023) and longer ICU LOS (incidence rate ratio (IRR) = 1.22; 95% CI = 1.05-1.41; z = 2.64; P = 0.008). Barotrauma occurred in 36/272 (13.2%) patients and was tracked with a higher driving pressure (subhazard ratio (SHR) per +5 cmH₂O = 1.58; 95% CI = 1.02-2.47; z = 2.23; P = 0.026).ConclusionIn a traumatic flail chest, integrating dead-space surrogates with driving pressure and dynamic compliance identifies high-risk ventilatory phenotypes and correlates with clinically relevant outcomes. Pending prospective validation, a practical titration bundle, routinely calculating and trending VR or AVDSf alongside driving pressure, aiming for a VR <1.5 and a driving pressure in the low-teens (e.g., ≤14 cmH₂O) while maintaining adequate perfusion, may complement analgesia and surgical stabilization pathways and help standardize ventilator management in trauma ICUs.

Case series: Suture lateralization for neonatal vocal fold movement disorders.

Right ventricular dysfunction on echocardiography to predict mortality in acute pulmonary embolism: an individual patient data meta-analysis.

Background: Point-of-care ultrasound (POCUS), and particularly the Focused Assessment with Sonography in Trauma (FAST), is widely used for the rapid detection of life-threatening internal injuries in trauma settings. In low-resource environments, where access to whole-body computed tomography may be limited, FAST plays a pivotal role in early triage and therapeutic decision-making. This study aimed to assess the diagnostic contribution of FAST in the initial evaluation of polytrauma patients admitted to the Emergency Department of Gabriel Touré University Hospital. Methods: We conducted a prospective, observational, descriptive study over six months (July–December 2022) in the Emergency Department of CHU Gabriel Touré, Mali. All trauma patients presenting with hemodynamic instability (systolic blood pressure ≤ 90 mmHg) were eligible. Non-consenting patients or those who died before undergoing FAST were excluded. Ultrasound examinations were performed using a Siemens Acuson X300 device equipped with cardiac, linear, and convex probes. Clinical, epidemiological, FAST findings, CT scan results, therapeutic interventions, orientation, and outcomes were collected and analyzed using SPSS 26.0, applying chi-square and logistic regression tests (significance threshold p &lt; 0.05). Results: A total of 42 polytrauma patients were included among 9050 trauma admissions (frequency 0.46%). Road traffic accidents predominated (80.95%), with high-energy mechanisms commonly observed: projection (35.71%), crushing (26.19%), and vehicle ejection (23.80%). Chest pain (90.50%) and dyspnea (42.85%) were the most frequent symptoms. FAST was pathological in 64.28% of patients, mainly showing hemoperitoneum (40.48%). Thoracic lesions detected on FAST included pneumothorax (9.52%), hemothorax (4.76%) and hemopneumothorax (9.52%). CT scans confirmed numerous severe injuries, including rib fractures (38.10%), flail chest (26.19%), and abdominal injuries in 78% of cases. Emergency interventions w

To determine whether a fetal right ventricular (RV) free-wall pericardial effusion (PE) is associated with alterations of ventricular geometry and function. Retrospective review of 1373 second- and third-trimester fetuses between 20 and 39 weeks of gestation was done to identify fetuses with a PE. Diastolic function was assessed via pulsed Doppler of RV and left ventricular (LV) inflow tracts, with monophasic filling in the presence of contralateral biphasic inflow classified as abnormal. End-diastolic RV and LV area, width, length, and sphericity were measured as well as systolic function. Z-score equivalent percentiles were computed for the above measurements. Statistical comparisons used published normative controls, with abnormalities defined as z-score equivalent percentiles (<10th or >90th percentile). Segmental movement of the ventricular free wall and septum was classified as hyperkinetic, hypokinetic, akinetic, and paradoxical. Four-chamber view (4CV), RV, and LV area, length, and mid-chamber width <10th percentile was more frequent than controls. Diastolic disturbance was selective to the RV: 87% (26/30) showed a monophasic tricuspid A-waveform with preserved mitral inflow. Systolic assessment revealed decreased (<10th percentile) RV and LV fractional area change, mid-chamber fractional shortening, as well as LV cardiac output and ejection fraction to be more frequent than controls as well as global and free-wall strain >90th percentile. Segmental analysis demonstrated high rates of paradoxical septal motion (33% LV, 73% RV) and regional akinesis. A localized right free-wall PE is associated with altered chamber geometry, selective diastolic impairment, discordant systolic deformation, and frequent paradoxical septal motion.

BackgroundTrauma remains a leading cause of death and disability in children. Effective initial assessment and structured management are vital to survival and recovery.ObjectivesTo present current principles of pediatric trauma care and highlight educational strategies that improve systematic assessment and intervention.ResultsEarly recognition of life-threatening conditions—catastrophic haemorrhage, severe head injury, airway obstruction, tension pneumothorax, massive hemothorax, flail chest, and cardiac tamponade—is critical. Immediate interventions such as airway stabilisation, tranexamic acid administration, massive haemorrhage protocol, chest decompression, and pelvic stabilisation can be lifesaving. Abdominal trauma requires prompt imaging and tailored surgical or conservative management. Head injury is the most common cause of pediatric trauma mortality; prevention of secondary brain injury through oxygenation, blood pressure control, ICP management, and timely neurosurgical intervention is essential. Cervical spine and spinal cord injury must always be suspected until excluded. Simulation-based training, adherence to protocols, and multidisciplinary coordination have demonstrated measurable benefits in team performance and patient outcomes.ConclusionsSystematic <C> ABCDE assessment, early targeted interventions, and structured training programs reduce preventable deaths in pediatric trauma. Head injury and haemorrhage remain the leading killers. Training and simulation improve clinician performance and outcomes. Education, focusing on rapid recognition, decision-making, and teamwork, bridges gaps between knowledge and practice.Key messages• Pediatric trauma care must follow a structured <C> ABCDE approach.• Life-threatening conditions require rapid, protocol-driven interventionsTopicPaediatric trauma, Life-threatening, Structured approach

BackgroundNasogastric tube syndrome (NGTS) is a rare yet potentially life‐threatening complication caused by prolonged compression of the laryngeal structures by a nasogastric tube, resulting in bilateral vocal fold paralysis and acute upper airway obstruction. While NGTS has been reported in patients requiring enteral feeding due to conditions such as stroke or impaired consciousness, no cases during the treatment of catatonia have been documented. NGTS remains underrecognized despite common nasogastric use in catatonia.Case PresentationThe patient was a 66‐year‐old woman with probable dementia with Lewy bodies who presented with catatonia characterized by psychomotor retardation. Due to impaired oral intake, a nasogastric tube was inserted for nutritional support. On the 38th day after the tube was inserted, she gradually developed stridor and worsening respiratory distress, followed by paradoxical breathing. Laryngoscopy revealed bilateral abductor vocal fold paralysis accompanied by marked arytenoid edema, and an emergency tracheostomy was performed. CT imaging confirmed arytenoid edema, while brain and cervical imaging revealed no evidence of central or peripheral lesions affecting the vagus or recurrent laryngeal nerves. Based on the clinical course and findings, a diagnosis of NGTS was made. Following removal of the nasogastric tube, vocal fold mobility gradually returned to normal. Her catatonic symptoms improved significantly after a course of electroconvulsive therapy.ConclusionThis case highlights the potential severity of NGTS in psychiatric settings. In patients with catatonia, who are often unable to communicate their symptoms, careful clinical monitoring is essential. When upper airway symptoms such as stridor or hoarseness arise during nasogastric feeding, NGTS should be considered as a possible cause. A multidisciplinary approach—including prompt consultation with otolaryngology—is crucial to prevent serious complications.

Objectives Out-of-hospital cardiac arrest (OHCA) remains a significant global health challenge. Cardiopulmonary resuscitation (CPR) plays a pivotal role in patient survival; the International Liaison Committee on Resuscitation (ILCOR) recommends compressions on the lower half of the sternum. However, emerging evidence suggests that performing compressions below this point, directly targeting the maximal diameter of the left ventricle, may improve cardiac output and clinical outcomes. This study assessed the safety of the new compression landmark by comparing complications with the standard approach. Methods This study was conducted as a randomized controlled trial using cadavers. The cadavers were assigned to two groups: The alternative landmark group received a mechanical chest compression cup that was placed 12.6 cm below the sternal notch, targeting the maximal diameter of the left ventricle. The nonintervention group used the standard landmark (lower half of the sternum). Each cadaver underwent pre- and post-chest compression computed tomography scans, followed by an autopsy to identify and compare complications. The primary outcome was the incidence of serious injuries. Secondary outcomes included the incidence of organ-specific injuries. Results Forty-two cadavers were equally assigned into two groups (21 per group). Serious injuries occurred similarly in the alternative and standard landmark groups (61.90% vs. 66.67%, p = 0.747). Rib cage injuries were similar between groups 11 (52.38%) versus 13 (61.90%) (p = 0.533). Flail chest affected 1 (4.76%) versus 3 (14.29%) (p = 0.293), and heart injuries were 2 (9.52%) versus 0 (p = 0.147). Skeletal fractures were universal, with sternal fractures in 16 (76.19%) versus 15 (71.43%) (p = 0.726). Visceral injuries were 7 (33.33%) versus 4 (19.05%) (p = 0.292). Liver and spleen injuries occurred only in the standard group (0% versus 4.76%, p = 0.312). No kidney injuries were reported. Conclusions The alternative landmark showed no significant difference in serious injuries compared to the standard landmark. Further studies should focus on chest compression at the new landmark, which has the potential to improve cardiac arrest outcomes.

Abstract Introduction Anti-synthetase syndrome (ASyS) is a rare, multisystem autoimmune disorder with characteristic manifestations of interstitial lung disease (ILD), myositis, and arthritis, and defined serologically by the presence of antibodies against aminoacyl-tRNA synthetases. Cardiac and renal manifestations are less common. Among pulmonary presentations, non-specific interstitial pneumonia (NSIP) is most frequently associated with ILD pattern. While myositis, typically accompanied by elevated creatine kinase (CK) levels, is a hallmark in most patients, it is rare for the syndrome to manifest as type 2 respiratory failure due to respiratory muscle involvement in the absence of CK elevation. Case description A 73-year-old man presented with acute delirium, followed by a comatose state due to severe type 2 respiratory failure. Chest X-ray showed bilateral pleural effusion and cardiomegaly. Blood tests revealed normocytic anaemia (116 g/L) and elevated CRP (187 mg/L). He needed non-invasive ventilation and was responding well; however, he struggled to be weaned off. An echocardiogram showed impaired ventricular systolic function and high pro-BNP levels (&amp;gt;7000 pg/ml). CK was normal. He was an ex-smoker who stopped 14 years ago, and had asthma. He had a history of progressive breathlessness post-COVID in late 2023. A CT chest showed interstitial changes consistent with smoking-related organising pneumonia. He also reported a one year history of weakness, lethargy, and a 20kg unintentional weight loss. He appeared emaciated, with muscle wasting, reduced chest expansion, and paradoxical chest movement. Electromyography (EMG) showed myopathic features without spontaneous activity and ultrasound revealed diaphragm palsy. Diagnosis of acid maltase deficiency or neuromuscular disease was suspected. Positive ANA, anti-Ro, and anti-Jo antibodies led to an MRI of the femurs, revealing diffuse muscle oedema. A muscle biopsy was planned but the patient did not consent. He was discharged on domiciliary BiPAP and scheduled for outpatient follow-up suspecting a diagnosis of obstructive lung disease and heart failure. Two months later, he re-presented with delirium and chest pain, along with a rising troponin level (&amp;gt;300 ng/L). No relevant ECG changes were noted. He became intolerant of BiPAP. He lapsed into a coma from hypercapnia and was placed on the amber care pathway for palliative care. CT chest from 2024 images reviewed showed changes of NSIP pattern. A diagnosis of anti-synthetase syndrome was made, and high-dose steroids were started. His respiratory failure improved rapidly, allowing BiPAP weaning to overnight use and oxygen weaned off. He was due to start on cyclophosphamide for induction. Discussion This patient presented with delirium, coma, and type 2 respiratory failure. Initial suspicion focused on chronic obstructive pulmonary disease (COPD), given a past smoking history. Heart failure was also considered, based on imaging and elevated pro-BNP and bilateral pleural effusion. However, widespread muscle wasting, normal creatine kinase (CK) levels, and myopathic features on EMG pointed toward a neuromuscular aetiology. Presence of constitutional symptoms prompted autoimmune screening, revealing positive ANA, anti-Ro, and anti-Jo-1 antibodies. MRI of the thighs showed proximal muscle oedema, suggesting inflammatory myopathy such as anti-synthetase syndrome (ASyS). However, with normal CK and the patient declining a muscle biopsy due to personal beliefs, the diagnosis remained uncertain. Rheumatology was re-consulted. A review of a prior CT chest revealed features of organising pneumonia and an NSIP pattern—findings that, alongside the autoantibodies and systemic features, strongly suggested ASyS with diaphragmatic involvement. High-dose steroids were initiated. This resulted in remarkable improvement within 48 hours, including complete resolution of coma, discontinuation of supplemental oxygen and need for BiPAP only during the night. Pleural effusions resolved over the following weeks. This case posed diagnostic challenges, particularly as CK was normal, and the patient’s smoking history and features of heart failures blurred the picture further. A high index of suspicion and timely immunosuppression led to a dramatic and life-saving reversal in this case. Key learning points 1. AsyS can present with predominantly respiratory symptoms causing type 2 respiratory failure due to diaphragmatic weakness. 2. A normal CK level does not exclude the diagnosis of inflammatory myositis and often results in a delay in diagnosis. 3. Smoking history and common diagnoses like COPD can obscure recognition of rare disease. 4. Re-evaluation of history and persistent assessment of diagnosis are crucial.

Patient: Male, neonateFinal Diagnosis: Paradoxical vocal fold motion (PVFM)Symptoms: Failure to thrive • feeding problems • inspiratory stridorClinical Procedure: —Specialty: Pediatrics and NeonatologyObjective: Unusual clinical courseBackgroundParadoxical vocal fold motion (PVFM) is characterized by inappropriate adduction of the vocal folds during inspiration, causing inspiratory stridor and feeding challenges. Its nonspecific symptoms and frequent co-occurrence with other conditions make diagnosis challenging. While PVFM is described in older children, neonatal cases remain rare and poorly understood. Limited data exists regarding its incidence, clinical features, and optimal management strategies, and no universally accepted guidelines exist for diagnosing neonatal PVFM.Case ReportThis case describes a term Hispanic male neonate diagnosed with PVFM at 18 days of life. The patient presented with persistent feeding difficulties, inspiratory stridor, and inadequate weight gain, requiring NICU admission. Flexible fiberoptic laryngoscopy (FFL) confirmed intermittent PVFM without structural anomalies. Management included an interdisciplinary care team, who facilitated anti-reflux therapy, gavage feeding, and eventual gastrostomy tube placement for feeding safety and failure to thrive. Despite continued stridor, gradual improvement occurred, with near-complete oral intake by 2 months. Repeat FFL at 68 days after diagnosis demonstrated normal vocal fold mobility.ConclusionsThis case underscores diagnostic challenges and management complexities of neonatal PVFM. FFL remains critical for confirmation, and supportive care with anti-reflux therapy can facilitate resolution. While the precise etiology remains unclear, associations include gastroesophageal reflux disease (GERD), neurological immaturity, and irritant exposure. These factors, combined with lack of definitive etiology, complicate clinical assessment and long-term planning. Standardized guidelines and further research into demographic and clinical predictors of PVFM are needed, especially for neonatal patients.

Objectives Trauma patients are a high volume and morbidity population, showing the importance of their prehospital care. This study aimed to evaluate the current status and consistency of prehospital trauma triage protocols in the United States. Methods States with statewide emergency medical services (EMS) protocols and trauma triage criteria were included. For each state, EMS protocols were analyzed to assess trauma centers and categories, trauma triage criteria (including physiologic, anatomic, mechanism, and patient factors), and transport mode and destination guidance. Results Of 31 states with statewide EMS protocols, 29 (94%) included prehospital trauma triage criteria. States most commonly had two (15 (52%) states) or four (nine (31%) states) trauma categories identified with colors, numbers, or letters. Systolic blood pressure (29 (100%) states), Glasgow Coma Scale (15 (52%) states), and respiratory rate (29 (100%) states) were the most frequently used physiologic criteria. Anatomic criteria included central penetrating trauma (29 (100%) states), bilateral femur fractures (26 (90%) states), open skull fractures (25 (86%) states), bilateral extremity paralysis (28 (97%) states), amputation above the wrist/ankle (28 (97%) states), unstable pelvic fracture (27 (93%) states), and flail chest (27 (93%) states). Death from the same mechanism (27 (93%) states), ejection (28 (96%) states), or pedestrian/bike versus automobile (29 (100%)) were mechanistic criteria for motor vehicle accidents. Patient factors, including age, anticoagulation, and pregnancy were patient factors used as trauma criteria. Destination differed by trauma category in 22 (76%) states, and helicopter transport was advised for drive times exceeding thresholds ranging from ten to sixty minutes. Conclusions In this national study of EMS protocols, we found heterogeneity in the structure and indications used for prehospital trauma triage criteria. This study highlights the need for standardization to ensure trauma patients receive timely and appropriate care.

ObjectiveCongenital diaphragmatic hernia (CDH) and congenital diaphragmatic eventration (CDE) exhibit overlapping imaging features that can contribute to diagnostic challenges. The aim of this study is to systematically and retrospectively examine the clinical and imaging characteristics of CDH and CDE to delineate their differences in diagnosis, treatment, and prognosis assessment, thereby providing a foundation for evidence-based clinical decision-making.MethodsA retrospective analysis was conducted on 78 cases of CDH and 20 cases of CDE diagnosed between January 2020 and December 2024 at a single institution. Imaging modalities reviewed included chest radiography, gastrointestinal contrast studies, ultrasonography, and computed tomography, in conjunction with clinical data. Key imaging parameters assessed were the integrity of the diaphragmatic contour, diaphragmatic motion, mediastinal displacement, thoracoabdominal organ position, pulmonary development, and amniotic fluid volume.ResultsThe sensitivity of X-ray and CT was (CDH 97.43% vs 100%, CDE 80.00% vs 90.00%), and the sensitivity of CT was higher than that of X-ray. The examination results were significantly associated with disease classification, which had statistical significance (P <0.05). In terms of diaphragm integrity and other malformations, CT examination showed significantly higher sensitivity than X-ray examination (100% vs 91.02%,6.41% vs 2.56%). However, in terms of paradoxical movement of the diaphragm, X-ray dynamic examination showed higher sensitivity than CT examination (80.00% vs 0%). Surgical management of CDH was more complex, influenced by the type and extent of the hernia as well as associated anomalies, and often necessitated intensive postoperative care. In contrast, surgical intervention for CDE was less complicated and associated with more favorable outcomes.ConclusionDespite certain overlapping imaging findings, CDH and CDE present distinct radiologic and clinical profiles. Comprehensive comparative imaging analysis enhances the understanding of their underlying pathophysiological differences, facilitates accurate diagnosis, and supports the development of tailored management strategies to improve clinical outcomes and long-term quality of life.

Introduction In cases of chest trauma, rib fractures are a frequently occurring injury, with a prevalence of 60-80%. As such, our study aimed to investigate the one-year prognosis for patients who have experienced chest trauma accompanied by rib fractures. Methods This study was cross-sectional. Seven hundred (700) patients with chest trauma and rib fracture were examined in terms of inclusion and exclusion criteria. Demographic data of patients, including age, gender, trauma mechanism (falling, car accident, motorcycle crash, and fight), and traumatic location (division into three anterior and posterior, and lateral positions) were recorded. The number of broken ribs, the presence of a flail chest, and some fractures of ribs were recorded. Complications created for patients included hemothorax, pneumothorax, hemopneumothorax, and pulmonary contusion based on chest CT scan and radiologist interpretation. The duration of hospital stay and admission to the intensive care unit were recorded. SPSS software version 22 was used to analyze the data. Results One-year mortality rate was 6.3%. Two hundred and two (202) patients (28.9%) had hemothorax, 115 patients (16.4%) with pneumothorax, 30 patients (4.3%) with hemopneumothorax, and 55 patients (7.9%) had a pulmonary contusion. The mean age of patients, duration of hospitalization, number of broken ribs, and injury severity score (AIS), criteria for dead patients were significantly higher than those who survived (p &lt;0.05). The frequency of hemopneumothorax, flail chest, and hospitalization in the intensive care unit in dead patients was significantly higher than in survivors (p &lt;0.05). Discussion According to the findings of this research, mortality rates in patients with chest blunt trauma and rib fractures are elevated in cases where the patient is of advanced age, experiences hemopneumothorax, sustains multiple rib fractures, has a higher AIS, endures a longer hospital stay, requires admission to the intensive care unit, and presents with a flail chest.

Multidisciplinary management of paradoxical vocal fold movement in infants: a case series and literature review.

Diaphragmatic palsy can result in respiratory failure, potentially alleviated by diaphragmatic plication. Nevertheless, the benefits of preventive plication during phrenic nerve resection remain uncertain. This study evaluated whether preventive plication during primary surgery involving phrenic nerve resection alleviate paradoxical diaphragmatic movement and pulmonary function loss. Among 24,527 surgeries for lung cancer or mediastinal tumors at 11 institutions, 142 involved phrenic nerve resections. Of these, 132 patients were retrospectively analyzed. Diaphragmatic displacement and pulmonary function were assessed pre- and postoperatively. Displacement was quantified by measuring thoracic height on pre- and postoperative chest X-rays (D, D'). Diaphragmatic displacement ratio was defined as: DDR = (D'-D)/D×100. Seventy patients (53%) underwent preventive diaphragmatic plication during the primary surgery; 62 (47%) did not. Differences were significant overall and more pronounced in those undergoing left lobectomy or more extensive resection. In this subgroup, plication was associated with a smaller change in DDR (-30.1 ± 7.7% vs. -20.2 ± 7.7%, p = 0.002), and smaller declines in percent predicted forced vital capacity (-30.5 ± 8.0% vs. -16.8 ± 17.7%, p = 0.029) and forced expiratory volume in one second (-31.6 ± 11.0% vs. -19.0 ± 14.5%, p = 0.046). In patients undergoing left lobectomy or more extensive resections involving phrenic nerve resection, intraoperative diaphragmatic plication may help preserve postoperative pulmonary function. However, due to the small sample size and limited generalizability, these findings should be interpreted cautiously.