Major Chest Trauma Research Articles

Long term outcomes following rib fracture fixation in patients with major chest trauma

Severe chest injuries are associated with significant morbidity and mortality. Surgical rib fixation has become a more commonplace procedure to improve chest wall mechanics, pain, and function. The aim of this study was to characterise the epidemiology and long-term functional outcomes of chest trauma patients who underwent rib fixation in a major trauma centre (MTC). This was a retrospective review (2014-19) of all adult patients with significant chest injury who had rib fixation surgery following blunt trauma to the chest. The primary outcome was functional recovery after hospital discharge, and secondary outcomes included length of intensive care unit (ICU) and hospital stay, maximum organ support, tracheostomy insertion, ventilator days. 60 patients underwent rib fixation. Patients were mainly male (82%) with median age 52 (range 24-83) years, injury severity score (ISS) of 29 (21-38), 10 (4-19) broken ribs, and flail segment in 90% of patients. Forty-six patients (77%) had a good outcome (GOSE grade 6-8). Patients in the poor outcome group (23%; GOSE 1-5) tended to be older [55 (39-83) years vs. 51 (24-78); p=0.05] and had longer length of hospital stay [42 (19-82) days vs. 24 (7-90); p<0.01]. Injury severity, rate of mechanical ventilation or organ dysfunction did not affect long term outcome. Nineteen patients (32%) were not mechanically ventilated. Rib fixation was associated with good long-term outcomes in severely injured patients. Age was the only predictor of long-term outcome. The results suggest that rib fixation be considered in patients with severe chest injuries and may also benefit those who are not mechanically ventilated but are at risk of deterioration.

Delayed Diagnosis of Traumatic Rupture of Anterior Papillary Muscle of Tricuspid Valve; Importance of Trans-Esophageal Echocardiogram in the Evaluation of Major Blunt Chest Trauma

Delayed Diagnosis of Traumatic Rupture of Anterior Papillary Muscle of Tricuspid Valve; Importance of Trans-Esophageal Echocardiogram in the Evaluation of Major Blunt Chest Trauma

The Potential Benefit of Emergency Ultrasound Plus MDCT for The Diagnosis of Major Chest Trauma … A Diagnostic Test Accuracy Study

Background: Multidetector computed tomography (MDCT) has established itselfas the preferred imaging modality for the evaluation of polytrauma patients owning to its significantly better ability in detecting tissue but patients are exposed to great amount of radiation during MDCT examination. Ultrasound has thebenefits of being reliable, dynamic, rapid, noninvasive technique and freed from radiation. Objective: This study aims toascertain the role of transthoracic ultrasound for imaging blunt chest trauma patients and compared its sensitivity, specificity and accuracy to those of MDCT as a gold standard modality. Patients and methods: This study was carried on 57 patients, 54 males (94.7%) and 3 were females (5.3%) and ages ranged from 5 to 60 years. All patients were exposed to major blunt chest trauma with or without associated polytrauma. Results: With MDCT as the gold standard, the most common injury detected by ultrasound (US) was pleural in 89.5% of patients with 96% accuracy, chest wall lesions were found in 80.7% of patients with 95% diagnostic accuracy, parenchymal lesions were found in 64.9% of patients with 91% diagnostic accuracy and mediastinal lesions were detected in 3.5% with 91% diagnostic accuracy. The sensitivity and specificity of ultrasonography varied for detecting thesubsequent pathologies: rib fracture (89% and 100%) subcutaneous emphysema (87% and100 %), hemothorax (94% and 100%), pneumothorax (89% and 100%), hydropneumothorax (81% and 100%), pulmonary contusions (82% and 100%), lung collapse (93% and 100%), lung laceration (100% and 100%) and hemopericardium (100% and100%), respectively. Conclusions: Chest US proved its value for diagnosis of blunt thoracic injuries with acceptable sensitivity and high specificity, particularly for pleural, pericardial and parenchymal lung injuries.

Physiotherapy management of patients with major chest trauma: Results from a global survey

Aim Major chest trauma is associated with significant morbidity and mortality. Management of patients with major chest trauma includes pain relief, ventilatory management, surgical fixation and early rehabilitation to improve both short- and long-term outcomes. Physiotherapy is widely considered an integral component of the multidisciplinary trauma team and aims to improve respiratory status and reduce the sequelae associated with immobility and reduced physical function. Despite this there is scarce evidence describing or investigating physiotherapy interventions and how these practices vary worldwide. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally. Methods A purpose designed online survey was administered to a group of experienced physiotherapists who work in the field of trauma. Results Response rate was 51% ( n = 49) and respondents represented all five continents. Respondents reported focussing on active coughing ( n = 46, 96%, r = 0.5, p = 0.98), body positioning ( n = 43, 94%, r = 0.7, p = 0.41), deep breathing exercises ( n = 44, 94%, r = 0.8, p = 0.66) and early mobilisation ( n = 47, 98%, r = 1, p = 0.64). Ambulation in hospital was reported to be common ( n = 46, 98%, r = 0.2, p = 0.99) but rehabilitation to address longer term sequelae following hospital discharge was reported to be rare ( n = 4, 8%). Conclusion This survey has highlighted those practices used by physiotherapists worldwide which aim to address the complications associated with major chest trauma. Having established global practice, the study provides a platform for future research investigating the efficacy of such interventions in improving both short- and long-term outcomes for patients following major chest injury.

Right main bronchus rupture due to blunt chest trauma.

Key Clinical MessageBronchial rupture following major blunt chest trauma should be suspected in every case of massive and persistent air leak through the intercostal drain tube. Chest radiogram offers indirect signs, while chest CT scan demonstrates specific signs highly suggestive for this extremely rare tracheobronchial injury. Bedside bronchoscopy confirms the diagnosis.

Acupuncture for chronic post-thoracotomy pain in a patient with major chest trauma: A case report

Acupuncture for chronic post-thoracotomy pain in a patient with major chest trauma: A case report

First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography

Combined clinical examination and supine chest radiography have shown low accuracy in the assessment of pneumothorax in unstable patients with major chest trauma during the primary survey in the emergency room. The aim of our study was to evaluate the diagnostic accuracy of extended-focused assessment with sonography in trauma (e-FAST), in the diagnosis of pneumothorax, compared with the results of multidetector computed tomography (MDCT) and of invasive interventions (thoracostomy tube placement). This was a retrospective case series involving 368 consecutive unstable adult patients (273 men and 95 women; average age, 25 years; range, 16-68 years) admitted to our hospital's emergency department between January 2011 and December 2012 for major trauma (Injury Severity Score ≥ 15). We evaluated the accuracy of thoracic ultrasound in the detection of pneumothorax compared with the results of MDCT and invasive interventions (thoracostomy tube placement). Institutional review board approval was obtained prior to commencement of this study. Among the 736 lung fields included in the study, 87 pneumothoraces were detected with thoracic CT scans (23.6%). e-FAST detected 67/87 and missed 20 pneumothoraces (17 mild, 3 moderate). The diagnostic performance of ultrasound was: sensitivity 77% (74% in 2011 and 80% in 2012), specificity 99.8%, positive predictive value 98.5%, negative predictive value 97%, accuracy 97.2% (67 true positive; 668 true negative; 1 false positive; 20 false negative); 17 missed mild pneumothoraces were not immediately life-threatening (thickness less than 5 mm). Thoracic ultrasound (e-FAST) is a rapid and accurate first-line, bedside diagnostic modality for the diagnosis of pneumothorax in unstable patients with major chest trauma during the primary survey in the emergency room.

Chest injuries associated with earthquakes: an analysis of injuries sustained during the 2008 Wen-Chuan earthquake in China

The goal of this study was to analyze the patterns, therapeutic modalities, and short-term outcomes of patients with chest injuries in the aftermath of the Wen-Chuan earthquake, which occurred on May 12, 2008 and registered 8.0 on the Richter scale. Of the 1522 patients who were referred to the West China Hospital of Sichuan University from May 12 to May 27, 169 patients (11.1%) had suffered major chest injuries. The type of injury, the presence of infection, Abbreviated Injury Score (AIS 2005), New Injury Severity Score (NISS), treatment, and short-term outcome were all documented for each case. Isolated chest injuries were diagnosed in 129 patients (76.3%), while multiple injuries with a major chest trauma were diagnosed in 40 patients (23.7%). The mean AIS and the median NISS of the hospitalized patients with chest injuries were 2.5 and 13, respectively. The mortality rate was 3.0% (5 patients). Most of the chest injuries were classified as minor to moderate trauma; however, coexistent multiple injuries and subsequent infection should be carefully considered in medical response strategies. Coordinated efforts among emergency medical support groups and prior training in earthquake preparedness and rescue in earthquake-prone areas are therefore necessary for efficient evacuation and treatment of catastrophic casualties.

Epidemiology of major paediatric chest trauma

Objective: Paediatric chest trauma is a marker of severe injury and a significant cause of morbidity and mortality. However, current trends in the Australian population are unknown. This study aims to outline the profile and management of major paediatric chest trauma in Victoria.

Epidemiology of major paediatric chest trauma

Paediatric chest trauma is a marker of severe injury and a significant cause of morbidity and mortality. However, current trends in the Australian population are unknown. This study aims to outline the profile and management of major paediatric chest trauma in Victoria. Prospectively collected data of patients from the Victorian State Trauma Registry from July 2001 to June 2007 were retrospectively reviewed. Data on fatalities were obtained from the National Coroners Information System. Descriptive statistics were used to summarise the profiles of major trauma cases and coroners' cases. Overall, 204 cases with serious paediatric chest injuries were reported by the Victorian State Trauma Registry (n = 158) and National Coroners Information System (n = 46) (excluding overlapping cases) in 2001-2007. Paediatric chest trauma was more common in males. The Injury Severity Score ranged from 16 to 25 in most patients. Blunt trauma was responsible for 96% of cases, of which motor vehicle collisions accounted for 75%. Median hospitalisation was 9 days, and 64% of patients were admitted to intensive care. Common injuries included lung contusion (66%), haemo/pneumothorax (32%) and rib fracture (23%). Multiple organ injury occurred in 99% of cases, with head (62%) and abdominal (50%) injury common. Management was conservative, with only 11 cases (7%) treated surgically. The highest mortality was in the 10-15-year age group. In 52 (79%) fatalities, injury was transport related. Australian paediatric chest trauma trends are similar to international patterns. Serious injury requiring surgical intervention is rare. This limited exposure may lead to difficulty in maintaining surgical expertise in this highly specialised area.

Risk Factors for 24-Hour Mortality After Traumatic Rib Fractures Owing to Motor Vehicle Accidents: A Nationwide Population-Based Study

Accurate identification of patients at high risk of death as a result of major chest trauma is essential within a trauma system. We used 3-year population-based data in Taiwan to evaluate risk factors associated with 24-hour mortality among adults with obvious rib fractures and needing hospitalization after traffic accidents. Pooled data from Taiwan's National Health Insurance Research Database for the years 2002 through 2004 were used. A total of 18,856 patients hospitalized with rib fractures after traffic accidents were included. Multivariate logistic regression using generalized estimating equations was performed to explore the relationship between 24-hour mortality and patients' age, sex, and comorbid conditions, as well as hospital characteristics, adjusting for social factors and any clustering of the sampled patients by hospital. Of patients in the sample, 459 (2.4%) died within 24 hours of admission. Patients who had six or more rib fractures were three times more likely to die within 24 hours of admission compared with patients with only one rib fracture (odds ratio [OR], 3.16; p < 0.001). The adjusted odds of death within 24 hours were higher for patients who had hemopneumothorax (OR, 3.15; p < 0.001), extremity fractures (OR, 1.74; p < 0.001), pelvic fractures (OR, 2.92; p < 0.001), head injuries (OR, 4.29; p < 0.001), spleen injury (OR, 1.83; p < 0.05), hepatic injury (OR, 4.39; p < 0.001), heart injury (OR, 4.48; p < 0.001), and diaphragm injury (OR, 3.16; p < 0.05) compared with patients who had none of these injuries. We concluded that more than six ribs fractured, heart injuries, hepatic injuries, head injuries, and advanced age are the most important determinants of 24-hour mortality after thoracic trauma from traffic accidents.

The imaging of paediatric thoracic trauma

Major chest trauma in a child is associated with significant morbidity and mortality. It is most frequently encountered within the context of multisystem injury following high-energy trauma such as a motor vehicle accident. The anatomic-physiologic make-up of children is such that the pattern of ensuing injuries differs from that in their adult counterparts. Pulmonary contusion, pneumothorax, haemothorax and rib fractures are most commonly encountered. Although clinically more serious and potentially life threatening, tracheobronchial tear, aortic rupture and cardiac injuries are seldom observed. The most appropriate imaging algorithm is one tailored to the individual child and is guided by the nature of the traumatic event as well as clinical parameters. Chest radiography remains the first and most important imaging tool in paediatric chest trauma and should be supplemented with US and CT as indicated. Multidetector CT allows for the accurate diagnosis of most traumatic injuries, but should be only used in selected cases as its routine use in all paediatric patients would result in an unacceptably high radiation exposure to a large number of patients without proven clinical benefit. When CT is used, appropriate modifications should be incorporated so as to minimize the radiation dose to the patient whilst preserving diagnostic integrity.

Blunt injuries of the chest

Blunt chest injuries are the most common form of thoracic trauma. Pulmonary and myocardial contusions are almost universal to some degree in major chest trauma and are usually managed non-surgically as are injuries to the chest wall. Pneumothorax and haemothorax require pleural drainage, and only rarely need an open thoracotomy for repair of the underlying injury. The majority of patients suffering from a significant major vessel, major airway and cardiac injury will die immediately. In those surviving to hospital their underlying condition may not be easy to diagnose, but prompt recognition and surgical treatment can be lifesaving. Awareness of the spectrum of important injuries and careful inspection of the initial chest radiograph supplemented by CT scanning allows most problems to be investigated appropriately and eventually diagnosed with confidence. Alterations to the usual ATLS management pathway may be necessary to ensure that the interventions normally used to resuscitate patients do not make their condition worse, e.g. endotracheal intubation for major airway trauma, excessive volume transfusion for cardiac tamponade. Patients suffering from blunt chest trauma usually have associated injuries in other parts of the body, especially with the abdomen so in those patients going to theatre for a thoracotomy, a laporotomy also should be seriously considered as an additional procedure.

Do We Really Need Routine Computed Tomographic Scanning in the Primary Evaluation of Blunt Chest Trauma in Patients with “Normal” Chest Radiograph?

A major cause of morbidity and mortality after blunt chest trauma remains undetected injuries. This study evaluates the role of routine computed tomographic (CT) scan. We studied 93 consecutive patients from January 1999 to July 2000: 73 (76.3%) after motor vehicle crash with crash speed > 10 mph, and 22 (23.7%) after fall from height > 5 ft. Simultaneous with initial clinical evaluation, anteroposterior chest radiograph and helical chest CT scan were obtained for all patients. Sixty-eight patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion. Over 50% of patients with normal initial chest radiograph showed multiple injuries on the CT scan, among which were also two (8%) potentially fatal aortic lesions. We therefore recommend primary routine chest CT scan in all patients with major chest trauma.

Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma.

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.

Pulmonary Atelectasis from a Posttraumatic Pseudoaneurysm of the Thoracic Aorta

Atelectasis of the left lung due to tracheobronchial compression is a rare complication of posttraumatic pseudoaneurysms of the thoracic aorta. We describe the case of a 57-year-old man with a chronic posttraumatic pseudoaneurysm of the thoracic aorta with acute progressive dyspnea and complete atelectasis of the left lung. The patient underwent aneurysmectomy with an interposition of a Dacron graft using both median sternotomy and lateral thoracotomy. A diagnosis of posttraumatic aneurysm should be considered in patients with both acute left pulmonary atelectasis and a history of major chest trauma. A review of the literature regarding this clinical condition is also discussed.

Identification of tension hemopneumothorax on supine chest radiograph: Value of the visceral pleural line sign

Tension hemopneumothorax is a life-threatening condition produced by either blunt or penetrating chest or thoracoabdominal trauma. The purpose of this study is to describe and illustrate the signs of tension hemopneumothorax on the supine chest radiograph. Review of the initial supine chest radiograph of 11 patients who were thought to have tension hemopneumothorax secondary to major blunt chest trauma constitutes the method of the study. The results of the study indicate that signs of tension hemopneumothorax include the visceral pleural line sign and shift of the mediastinal structures to the opposite side with or without a deep sulcus sign. These observations on the supine chest radiograph were confirmed by erect chest radiography in one patient, axial computed tomography in two patients, and clinically at the time of tube thoracostomy and by postthoracostomy intubation supine chest radiographs in eight patients. We conclude, therefore, that tension hemopneumothorax is recognizable on supine chest radiographs by the visceral pleural line sign and contralateral mediastinal shift with or without a deep sulcus sign, that tension hemopneumothorax is distinguishable from hemopneumothorax, hemothorax, and extrapleural hematoma, and that the radiologic distinction is clinically significant.

Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation

A total of 427 patients with major chest trauma were treated in two major hospitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426 patients, flail chest injury was the dominant factor among other injuries that were insignificant. Among 64 cases of flail chest injury, 26 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotracheal intubation and intermittent positive-pressure ventilation alone. Of the patients treated by internal fixation 80% (21/26) were weaned from the ventilator within an average of 1.3 days, whereas the remaining 20% (5/26) continued to need assisted ventilation for a longer duration; the total average duration of assisted ventilation for the whole group was 3.9 days. In comparison, among 38 patients with flail chest injury treated by endotracheal intubation and ventilation alone, the average duration of assisted ventilation was 15 days. In the group treated by internal fixation 11% (3/26) of the patients ultimately required a tracheostomy, whereas in the patients treated by intubation and ventilation alone tracheostomy was required in 37% (14/38) of the cases. In the group treated by internal fixation, chest infection was documented in 15% (4/26), septicemia in 4% (1/26), and barotrauma in 0%; in the other group these complications occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients, whereas it was 29% (11/38) in the other group. All the deaths in both groups were ascribed to adult respiratory distress syndrome. Average stay in the intensive care unit was 9 days for the patients treated by internal fixation, whereas it was 21 days in the group treated by intubation and ventilation alone. The treatment of flail chest injury in our series by internal fixation resulted in speedy recovery, decreased complications, and better ultimate cosmetic and functional results and proved to be cost effective. (J T HORAC C ARDIOVASC S URG 1995;110:1676-80)

Traumatic Rupture of the Aorta

The report in this issue of the Journal by Smith et al.1 on the use of transesophageal echocardiography in the diagnosis of traumatic disruption of the thoracic aorta represents an important step forward in the evaluation of patients with major chest trauma. Rupture of the aorta is a frequent cause of death after trauma. Most patients who sustain such injuries die at the trauma scene from sudden, massive exsanguination. For those who survive to reach a trauma center, a high index of suspicion for the injury on the part of clinicians, sensitive diagnostic tests to confirm or exclude the diagnosis, . . .

Crocodile attacks in the Northern Territory of Australia.

To examine crocodile attacks in the Northern Territory with particular reference to risk factors, range of injuries, microorganisms isolated from wounds, and surgical management; and to make recommendations for optimal treatment. The case notes of patients treated at the Royal Darwin Hospital within the last decade were reviewed retrospectively. Autopsy and newspaper reports for the same period were also reviewed. There were 16 reported crocodile attacks in Northern Territory waters from June 1981 to June 1991. Four of these were fatal. Most attacks resulted from swimming or wading in shallow water (13/16). Half the victims were known to be affected by alcohol. The majority of attacks occurred in failing light or at night (10/16). Injuries in survivors ranged from minor lacerations and puncture wounds to major abdominal, chest and limb trauma. Death in fatal attacks was caused by transection of the torso or decapitation. Microorganisms isolated from wound swabs included Pseudomonas, Enterococcus, Aeromonas and Clostridium species. Most attacks in this series could have been prevented by taking adequate precautions. The treatment of crocodile injuries must include (i) adequate wound cultures, (ii) antitetanus prophylaxis, (iii) meticulous wound debridement, (iv) appropriate broad spectrum prophylactic antibiotics and (v) allowing healing by secondary intention or delayed primary closure where appropriate.