Major Chest Research Articles

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.

Editorial on “occult cervical nodal metastases in esophageal cancer: Preliminary results of three-field lymphadenectomy”

Editorial on “occult cervical nodal metastases in esophageal cancer: Preliminary results of three-field lymphadenectomy”

Chest Wall Reconstruction

Chest wall resection and reconstruction continue to provide a formidable challenge. Prolonged hospitalization of 2 to 3 weeks in often necessary, and patients at our institution have undergone an average of two operations to achieve final closure. However, in multiple reviews of the senior author's personal experience, 85% of patients alive 30 days after operation had a healed, asymptomatic chest wall. Most late deaths occur as a result of the underlying disease process, usually malignancy.

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.

Erroneous interpretation of magnetic resonance images of a fracture of the first rib with non-union. Two case reports.

The first rib is the highest, strongest, flattest, and most curved of all of the ribs. Fractures from direct trauma are rare and usually are associated with major chest and abdominal injuries. Isolated stress fractures with non-union of the first rib, particularly as a result of sports activities, have been described in several reports. The diagnosis of a fracture of the first rib traditionally has been made from plain radiographs and bone scans. However, because of the rarity of the fracture and a general unfamiliarity with it, a physician is likely to obtain a magnetic resonance image to aid in the diagnosis of a lesion of the first rib because that modality offers superb soft-tissue contrast and a high sensitivity to changes in intraosseous signal intensity. The purpose of this paper is to report our experience with two patients who had a fracture of the first rib with non-union ; the interpretation of the magnetic resonance images led to an overestimation of the seriousness and the extent of the lesions, with resultant confusion regarding the diagnosis.

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)

Thoracoscopy vs Conventional Autopsy of the Thorax

To analyze the sensitivity and specificity of thoracoscopic autopsy compared with that of conventional postmortem examination. Consecutive sampling, case-series study. A general community referral center and the local Institute of Forensic Medicine. A consecutive sample of 20 fresh cadavers (less than 24 hours old), victims of motor vehicle crashes, gunshot wounds, in-hospital deaths. Introduction of the thoracoscope through the fourth or fifth intercostal space, anterior or midaxillary line. The pleural cavity and mediastinum were examined. Formal postmortem examination was then performed, and the findings of both procedures were recorded, compared, and analyzed. Prior to the beginning of the study, it was hypothesized that thoracoscopic autopsy would reach an overall sensitivity and specificity of at least 85% and enable accurate inspection of the thoracic cavity and mediastinum in search of trauma-related abnormalities in trauma victims or cause of death in in-hospital patients. There was an 85% correlation of both procedures in all cases. The sensitivity of thoracoscopic autopsy was 87% and overall specificity reached 72%. Thoracoscopic autopsy is accurate and easy to perform. It is highly sensitive, especially in deaths due to trauma and following thoracic surgery. Thoracoscopic autopsy is an important tool that allows the diagnosis of major chest abnormalities as well as ruling out postoperative catastrophe, information that is invaluable for the surgeon, as well as all the medical staff and families. Thoracoscopic postmortem examination should be offered to mourning families as a cosmetic and reliable option when informed consent for conventional autopsy is lacking.

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, . . .

BENIGN CYSTIC TERATOMA OF THE MEDIASTINUM PRESENTING AS RECURRENT PNEUMONIA AND SIMULATING MALIGNANCY

We describe a case in whom recurrent pneumonia was the presenting manifestation of a benign cystic teratoma of the mediastinum. Although the symptoms had developed over a 15-year period, the mass was not identified on the chest roentgenograrns up to the age of 22 years. CT demonstrated the extent of the mass, but failed in clarifying the cystic nature of the tumor and in providing diagnosis. The lesion could be safely approached through an antero-lateral thoracotomy, saving major chest wall muscles. However, surgical removal of the mass was difficult because of firm adherence to surrounding structures.

Epidemiology of silent myocardial ischemia in asymptomatic middle-aged men (the ECCIS Project)

To evaluate the prevalence of type I silent myocardial ischemia and silent myocardial infarction, 4,842 men aged 40 to 59 years, identified in occupational samples in Florence and Rome, and free from major heart disease, severe illnesses and chest pain, underwent a 3-stage diagnostic procedure. The first stage included resting electrocardiogram, hyperventilation test, exercise electrocardiogram and 24-hour Holter electrocardiogram. The subjects who were suspected of having type 1 silent myocardial ischemia or previous silent infarction at the first stage (n = 439; 9.1%) were entered into the second stage, which included echocardiogram, thallium 201 sintigraphy in conjunction with exercise testing or dipyridamole test, exercise radionuclide ventriculography and ergonovine test. Three hundred eighty-seven men participated in the second stage; after the diagnostic procedures were performed, 104 men (2.1%) were still suspected of having type 1 silent myocardial ischemia or infarction on the basis of predefined criteria. Sixty-two men continued on into the third diagnostic workup including coronary angiography. The final diagnosis of type 1 silent myocardial ischemia or infarction was reached in 25 patients (prevalence 0.52%; adjusted estimate 0.89%). Of these 25, 19 had coronary atherosclerotic disease, 1 had Kawasaki disease, 1 had coronary anomaly, 1 had induced focal coronary spasm, and 2 had normal coronary arteriograms despite the presence of unquestionable old myocardial infarction. Altogether, 6 patients with silent myocardial infarction were identified. The coronary profile, based on the measurement of a number of coronary risk factors, was definitely worse in the 25 subjects with type 1 silent myocardial ischemia or previous silent infarction than in the other subjects.

Diagnosis of myocardial contusion.

From July 1988 to July 1990, 159 consecutive cases of major blunt chest injury were evaluated prospectively for myocardial contusion with serial electrocardiographic monitoring, cardiac isoenzyme studies, and two-dimensional echocardiography. One hundred and forty-seven cases in the series were assessable; 97 of the patients were male, and 50 were female. They ranged in age from 2 to 97 years (average, 38.5 years). There were five deaths, none of cardiac origin. Total lactate dehydrogenase (LDH) values were elevated in 115 patients (78%); total creatine phosphokinase (CPK) values were elevated in 100 (68%). Cardiac isoenzyme patterns were consistent with myocardial contusion in 18 patients (12%). Seventy-five patients had abnormal electrocardiograms, and 10 of these had ectopic rhythms. Two-dimensional echocardiograms were completed in 58 cases; 12 of these (21%) were abnormal. Nineteen patients (25%) with abnormal rhythms had elevated LDH values, and 26 (35%) had elevated CPK values. One patient (10%) with ectopy had an abnormal echocardiogram. Two patients (11%) with abnormal isoenzyme patterns experienced dysrhythmias. Costs for hospitalization and studies amounted to $1,886 per patient. Given the poor predictive value of laboratory testing in patients with significant (ie, symptomatic) cardiac contusion, observation alone with electrocardiographic monitoring and treatment of symptomatic dysrhythmias is an adequate and cost-conscious treatment.

Caregiver-infant interaction--comforting post-operative neonates.

Analysis of 40 h of videotaped caregiving to four male infants was conducted using ethology. All infants were full term and had major chest surgery 12 h previously. All incidents of caregiver-infant interaction were examined, and the verbal and tactile comforting behavior of the caregiver was coded for duration, context, infant cue and infant state prior and following the interaction. A total of 191 comforting incidents occurred during the study. Stroking was the most common form of touch used. Most of the comforting (60%) was given in the context of caregiving; sleeping infants were touched often (38%); 25.3% of the touches were given to acutely distressed infants, and wide awake infants relatively little. Most of the infants showed no change in infant state after the relatively brief comforting incidents, but in 15.7% of the incidents the infants 'settled' after comforting. The authors conclude that this is a relatively strong effect considering the short duration of the comforting actions.

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.

Reconstruction of the chest wall with e-PTFE following major resection.

Nine patients underwent major chest wall resection at Thomas Jefferson University Hospital (Philadelphia, PA) over a 19-month period. Chest wall reconstruction was performed with an expanded polytetrafluoroethylene (e-PTFE) soft tissue patch (Gore-Tex) and vascularized flaps in all patients. The size of the skeletal defects ranged in area from 60 to 400 cm2. The primary indications for resection included chest wall sarcoma and radiation ulcer. Aggressive chest wall resection may be a patient's only opportunity for cure and an improved quality of life. In this series, chest wall resection was able to be performed with a low morbidity and no mortality. This study also demonstrates many of the advantages of e-PTFE as a chest wall substitute compared with other previously described prosthetic materials. The use of a Gore-Tex patch along with described flaps for soft tissue coverage provides good functional and aesthetic results.

A new method of stabilizing the chest wall following major chest wall resection

Prosthetic materials, such as metals, marlex mesh and methyl methacrylate have been used for stabilization of the chest wall after resection of large areas of rib cage. Such materials are contraindicated in an infected area. A new method of providing a stable chest wall using autogenous tissue is presented.

Blunt traumatic rupture of pulmonary vein, left atrium, and bronchus

A 22-year-old man fell 12.2 m (40 ft), injuring the right lower lobe bronchus, right inferior pulmonary vein, and left atrium. These injuries were not associated with fractures, cardiac tamponade, or pneumothorax. The severity of injury became apparent only upon right thoracotomy for persistent hemorrhage. This case presented special diagnostic and surgical challenges and suggests a role for the increased use of bronchoscopy in major blunt chest trauma.

Base deficit as an indicator of significant abdominal injury

To determine the relative predictive value of the arterial base deficit (BD) as an indicator of intra-abdominal injury (AI) and to compare BD with other indicators (chest injuries, pelvic fractures) of AI. Retrospective case-control analysis. University of California San Diego Medical Center. Between January 1985 and July 1988, 3,223 blunt trauma patients were admitted, with complete records available on 3,011. Using a "best fit" multiple logistic regression, BD less than or equal to -6 was the single most important indicator of AI (P less than or equal to .0001), and the odds ratio for AI increased with each category of increasing severity of BD. Admission hypotension, major chest injury, pelvic fracture, and field hypotension (in odds ratio order) also were significantly associated with AI. BD is a powerful indicator of AI. A normal BD does not exclude AI, but the presence of a BD less than or equal to -6 in a blunt trauma patient should be considered a strong indication for objective evaluation of the abdomen (ie, diagnostic peritoneal lavage).

Postoperative Analgesia in Children

Few advancements in postoperative pain control in children have been made despite longstanding inadequacies in conventional intramuscular analgesic regimens. While overestimating narcotic complication rates, physicians often underestimate efficacious doses, nurses are reluctant to give injections, and many children in pain shy away from shots. This study prospectively focuses on the safety, efficacy, and complication rate of intermittent intramuscular (IM) versus continuous intravenous infusion (IV) of morphine sulfate (MS) in 46 nonventilated children following major chest, abdominal, or orthopedic surgical procedures. Twenty patients assigned to the IM group had a mean age of 6.17 years and a mean weight of 23.0 kg. Twenty-six patients assigned to the IV group had a mean age of 8.74 years and a mean weight of 27.4 kg. The mean IM MS dose was 12.3 micrograms/kg/h while the mean IV dose was 19.8 micrograms/kg/h (P less than .001). Postoperative pain was assessed with a linear analogue scale from 1 to 10 (1, doesn't hurt; 10, worst hurt possible) for 3 days following operation. Using the analysis of covariance (ANACOVA), nurse, parent, and patient mean pain scores in the IV group were significantly lower than those of the IM group when controlled for age, MS dose, and complications (P less than .007). Nurse assessment of pain correlated well with the patient and parent assessments (Pearson correlation coefficients greater than 0.6). Not only did IV infusion give better pain relief than IM injections, but there were no major complications such as respiratory depression. Minor complications in this study (nausea, urinary retention, drowsiness, vomiting, hallucinations, lightheadedness, and prolonged ileus) were not significantly different between IM and IV groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Three or More Rib Fractures as an Indicator for Transfer to a Level I Trauma Center

The presence of major chest wall injury is an indication for transfer to a Level I trauma center. We hypothesized that the presence of three or more rib fractures on initial chest X-ray would identify a small subgroup of patients with a high probability of requiring trauma center care. All trauma discharges in Maryland between 1984 and 1986 (N = 105,683) were reviewed. Patients were divided by the presence of rib fractures (no rib fractures, 1-2 fractures, 3+ fractures) and age in years (0-13, 14-64, 65+). The presence of three or more rib fractures in the pediatric age group was rare and precluded further evaluation. When comparing patients with 1-2 rib fractures versus 3 or more rib fractures, significant differences were found in mortality, mean Injury Severity Score, mean hospital stay and mean number of ICU days (p less than 0.001). The significant differences occurred in all age groups 14 years old and older. The presence of three or more rib fractures increased the relative risk of splenic injury (6.2) and liver injury (3.6) but did not predict the presence of aortic injury. The presence of 3 or more rib fractures identifies a small subgroup of patients (2.4%) likely to require tertiary care. This triage tool is useful in all patients over the age of 14 years.

Postoperative analgesia in children: A prospective study of intermittent intramuscular injection versus continuous intravenous infusion of morphine

Few advancements in postoperative pain control in children have been made despite longstanding inadequacies in conventional intramuscular analgesic regimens. While overestimating narcotic complication rates, physicians often underestimate efficacious doses, nurses are reluctant to give injections, and many children in pain shy away from shots. This study prospectively focuses on the safety, efficacy, and complication rate of intermittent intramuscular (IM) versus continuous intravenous infusion (IV) of morphine sulfate (MS) in 46 nonventilated children following major chest, abdominal, or orthopedic surgical procedures. Twenty patients assigned to the IM group had a mean age of 6.17 years and a mean weight of 23.0 kg. Twenty-six patients assigned to the IV group had a mean age of 8.74 years and a mean weight of 27.4 kg. The mean IM MS dose was 12.3 μg/kg/h while the mean IV dose was 19.8 μg/kg/h ( P < .001). Postoperative pain was assessed with a linear analogue scale from 1 to 10 (1, “doesn't hurt”; 10, “worst hurt possible”) for 3 days following operation. Using the analysis of covariance (ANACOVA), nurse, parent, and patient mean pain scores in the IV group were significantly lower than those of the IM group when controlled for age, MS dose, and complications ( P < .007). Nurse assessment of pain correlated well with the patient and parent assessments (Pearson correlation coefficients > 0.6). Not only did IV infusion give better pain relief than IM injections, but there were no major complications such as respiratory depression. Minor complications in this study (nausea, urinary retention, drowsiness, vomiting, hallucinations, lightheadedness, and prolonged ileus) were not significantly different between IM and IV groups. Continuous IV morphine infusion is a safe and more effective means of postoperative pain control in children.