Open Chest Wounds Research Articles

Chest wall reconstruction in a young man after high-velocity gunshot using a combination latissimus dorsi flaps and titanium plates: A case report.

Chest trauma, penetrating or blunt, is common in this era of road traffic accidents, terrorism, and hunting in Iraq. During the last decade, many novel surgical procedures and materials were used to reconstruct or stabilize the chest wall to improve integration, maintain the stability of the chest wall, and reduce infections. However, no precise guidelines for managing chest wall diseases are still available to date. Here, we present a 24-year-old male who underwent chest wall reconstruction using a combination of latissimus dorsi flap and titanium plates, which were to cover the chest wall after a high-velocity gunshot. This patient was in shock too, with a lung contusion and massive hemorrhage. The sucking open chest wound lead to grossly disturbed respiratory mechanics. Such patients usually die on the way due to hemodynamic instability. In this particular case, adequate resuscitation and prompt thoracotomy saved the patient's life. This case report is important because, as we already mentioned, thoracic trauma alone is the cause of death in 25% of patients, and in another 25%, it's a contributing factor in a polytrauma death. This amounts to very high mortality. Our patient received a major laceration of the left lung. Our patient had a full recovery from this life-threatening situation.

Use of a Dermal Matrix for an Open Chest Wound in a Newborn with Complicated Necrotizing Fasciitis.

Use of a Dermal Matrix for an Open Chest Wound in a Newborn with Complicated Necrotizing Fasciitis.

TRAUMATIC CHEST WALL INJURY WITH DIAPHRAGMATIC RUPTURE AND LUNG HERNIATION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Traumatic diaphragmatic injuries are a rare injury that can occur after chest wall trauma. Injury to the diaphragm and its surrounding structures can easily be missed as the patients often have polytrauma. We present a case of a penetrating injury with blunt traumatic chest wall injury with diaphragm rupture and herniation of the left lung through the chest wall after a motorcycle collision. CASE PRESENTATION: A 24-year-old male presented to the hospital as a trauma alert after a motorcycle crash. The patient was found to have a large open chest wound with exposed lung and diaphragm. He was taken for CT imaging and found to have a left apical pneumothorax, left lung contusion, left rib fractures 2-10, and a grade 2 spleen laceration. The patient was taken for emergent exploration of his left chest wound. The patient was found to have disruption of his left chest wall and diaphragmatic attachments with rupture of the lateral aspect of his diaphragm at the level of rib 5-6. The wound was explored with evidence of injury to the left inferior lateral lobe of his lung. The lung did not require any resection. The entire left diaphragm was examined with the central tendon of the left diaphragm found to be intact, the diaphragm was repaired along the lateral edge and reattached to the costal cartilage laterally along the chest wall. The left chest was washed out and a chest tube was placed. The patients remaining hospital course was uneventful, and his chest tube was removed with no signs of air leaks. DISCUSSION: There are no specific signs of diaphragmatic injury or rupture on physical exam. Missed diaphragmatic injuries can result in major morbidity or mortality for the patient. All diaphragmatic injuries should be examined along with all surrounding structures at the time of diagnosis. Most diaphragmatic injuries occur on the left side as the right side is protected by the liver. We highly recommend CT imaging to examine the upper abdomen and chest. In the case of our patient which is rare, we were able to visualize his chest wall injury with his diaphragmatic injury on physical exam. When diagnosed early we recommend repair through the abdomen, but if found late repair through the chest is a better approach. In our case we were able to re-approximate the diaphragm to the chest wall. CONCLUSIONS: Traumatic injuries to the diaphragm can be tough to diagnose at times when there is not obvious injury noted to the diaphragm. We recommend full exposure of the diaphragmatic surface and examination of the surrounding organs and structures to rule out further injury that is not obvious on first examination. The diaphragm should be repaired and then reattached to the chest wall along its costal cartilage laterally. Complete repair with reattachment will allow the patient to avoid morbidity and mortality of a chronic diaphragmatic injury that could lead to impaired respiratory or chest wall function. REFERENCE #1: DeBarros, M., Martin, M.J. Penetrating Traumatic Diaphragm Injuries. Curr Trauma Rep 1, 91-101 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by Alyssa Ritchie, source=Web Response

First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma-related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Development of a New Vented Chest Seal Dressing for Treatment of Open Pneumothorax.

The most common life-threatening complications from both blunt and penetrating thoracic injury are hemothorax, pneumothorax, or a combination of both. New guidelines, set out by the Tactical Combat Casualty Care (TCCC), advises that vented chest seal dressings are used to manage open or sucking chest wounds. Designing out risk is a fundamental criterion for ensuring the optimal performance of a device is obtained that offers the casualty the greatest chance of survival. Two key areas of risk in the application of vented chest seal dressings are adhesion failure and vent failure. This study assesses a new design of vented chest seal dressing for both adhesion and vent profile. The development of this new design for a vented chest seal has been tested for adhesion and venting properties and shown to have performance criteria suitable for the treatment of open pneumothorax and design features that minimize the risk of product failure during use.

Efficacy of Head and Torso Rewarming Using a Human Model for Severe Hypothermia

To evaluate the rewarming effectiveness of a similar amount of heat (from a charcoal heater) applied to either the head or torso in a human model for severe hypothermia in which shivering is pharmacologically inhibited in mildly hypothermic subjects. Six male subjects were cooled on 3 different occasions, each in 8°C water for 60 min, or to a lowest core temperature of 35°C. Shivering was inhibited by intravenous meperidine (1.5 mg·kg-1), administered during the last 10 min of the cold-water immersion. Subjects then exited from the cold water, were dried, and were placed in a 3-season sleeping bag for 120 min in one of the following conditions: spontaneous rewarming only, charcoal heater on the head, or charcoal heater on the torso. Supplemental meperidine (to a maximum cumulative dose of 3.3 mg·kg-1) was administered as required during rewarming to suppress shivering. No significant differences were found in the postcooling afterdrop amount or core rewarming rates among the 3 conditions (0.8°C·h-1). During the last 30 min of rewarming the net heat gain was significantly higher in the head (85.8±25.3 W) and torso (81.5±6.3 W) conditions compared with the spontaneous condition (56.9±12 W) (P<0.05). In our study, head and torso warming had the same core rewarming rates when shivering was pharmacologically inhibited in mildly hypothermic subjects. Therefore, in nonshivering cold subjects, head warming is a viable alternative if torso warming is contraindicated (eg, when performing cardiopulmonary resuscitation or working on open chest wounds).

Contemporary stethoscope cleaning practices: What we haven't learned in 150 years

Stethoscopes can be microorganism reservoirs. The US Centers for Disease Control and Prevention (CDC) has published medical equipment disinfection guidelines to minimize infection transmission risk, but studies of guideline adherence have been predominately survey based, with little direct observation of disinfection practices. We performed an observational, cross-sectional, anonymous study of patient-provider interactions, assessing practitioners' frequency and methods of stethoscope and hand disinfection practices. Stethoscopes were disinfected in 18% of 400 observed interactions, with less than 4% verified as conforming to CDC guidelines. None was disinfected before patient examinations involving open chest or abdominal wounds, as recommended by the CDC. Hands were cleaned before and after encounters 27 times (6.8%) but were not cleaned at all in 231 (58%) encounters, although gloves were worn in 197 (85.3%) of these cases. Stethoscope disinfection is grossly overlooked, possibly jeopardizing patient safety, particularly in acute care interactions. Periodic stethoscope disinfection, although inconvenient, helps reduce bacterial contamination and may reduce health care-associated infections. Stethoscopes were disinfected per CDC guidelines in less than 4% of encounters and were not disinfected at all in 82% of encounters. Although hands were rarely cleaned (6.8%) per CDC guidelines, gloves were usually worn, but no convenient stethoscope equivalent exists. Stethoscope cleanliness must be addressed.

A RARE CASE OF TRAUMATIC PENETRATING CHEST INJURY WITH HEMOPNEUMOTHORAX

Thoracic trauma contributes to one-quarter of trauma deaths. Traumatic hemothorax is commonly associated with organ damage, such as rib fracture, lung injury, and diaphragm rupture and usually occurs immediately after trauma. Here, we report the case of an 18-year-old male patient of a road traffic accident. He was admitted with an open chest wound and fractured ribs with exposed heart, left hemidiaphragm, left lung, and left thoracic cavity. He had fractured lower ribs with the contusion of intercostal and pectoral muscles. The wound was explored proper toileting of the wound, and the left chest cavity was done. A tear in the left lung was repaired, ribs were positioned, and the chest wall was reconstructed without using any prosthesis. In the post-operative period, the patient developed partial flap necrosis and so he was referred to plastic surgery where debridement and pedicled latissimus dorsi flap were applied. The patient got discharge after about 1 month of the post-operative period.

Danish first aid books compliance with the new evidence-based non-resuscitative first aid guidelines

BackgroundThe European Resuscitation Council (ERC) released new guidelines on resuscitation in 2015. For the first time, the guidelines included a separate chapter on first aid for laypersons. We analysed the current major Danish national first aid books to identify potential inconsistencies between the current books and the new evidence-based first aid guidelines.MethodsWe identified first aid books from all the first aid courses offered by major Danish suppliers. Based on the new ERC first aid guidelines, we developed a checklist of 26 items within 16 different categories to assess the content; this checklist was adapted following the principle of mutually exclusive and collectively exhaustive questioning. To assess the agreement between four raters, Fleiss’ kappa test was used. Items that did not reach an acceptable kappa score were excluded.ResultsWe evaluated 10 first aid books used for first aid courses and published between 2009 and 2015. The content of the books complied with the new in 38% of the answers.In 12 of the 26 items, there was less than 50% consistency. These items include proximal pressure points and elevation of extremities for the control of bleeding, use of cervical collars, treatment for an open chest wound, burn dressing, dental avulsion, passive leg raising, administration of bronchodilators, adrenaline, and aspirin.ConclusionsDanish course material showed significant inconsistencies with the new evidence-based first aid guidelines. The new knowledge from the evidence-based guidelines should be incorporated into revised and updated first aid course material.

Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model.

Airways compromise was the second leading cause of potentially preventable death among combat casualties. We investigated the ability of five Food and Drug Administration-approved nonocclusive chest seals (CSs) to seal a bleeding chest wound and prevent tension hemopneumothorax (HPTX) in a swine model. Following instrumentation, an open chest wound was created in the left thorax of spontaneously air-breathing anesthetized pigs (n = 26; 43 kg). Autologous fresh blood (226 mL) was then infused into the pleural cavity to produce HPTX. The chest wounds were then sealed with CSs. The sealant strength and venting function of CSs were challenged by infusion of 50 mL more blood directly into the chest wound and incremental air injections into the pleural cavity. Tension HPTX was defined as intrapleural (IP) pressure equal to or more than +1 mm Hg and more than 20% deviation in physiologic measurements. An open chest wound with HPTX raised IP pressure (~ -0.7 mm Hg) and caused labored breathing and reductions in PaO2 and SvO2 (p < 0.01). Sealing the wounds with the CSs restored IP pressure, and improved breathing and oxygenation. Subsequent blood infusion into the wound and IP air injections produced CS-dependent responses. Chest seals with one-way valves (Bolin and SAM) did not evacuate the blood efficiently; pooled blood either detached the CSs from skin and leaked out (75%), or clotted and clogged the valve and led to tension HPTX (25%). Conversely, CSs with laminar venting channels allowed escape of blood and air from the pleural cavity and maintained IP pressure and oxygenation near normal levels. Success rates were 100% for Sentinel and Russell (6/6); 67% for HyFin (4/6); 25% for SAM (1/4); and 0% for Bolin (0/4) CSs (p = 0.002). The sealant and valve function of vented CS differed widely in the presence of bleeding chest wounds. Medics should be equipped with more effective CSs for treating HPTX in the field.

Open Chest Wounds and Missed Injuries - A Really Opened Pandora's Box.

The purpose of the study is to highlight the importance of systematic approach and investigation for identification of potential life threatening lesions to a serious injured patients with the presence of obvious other lesions. Material and method: A clinical case patient, with penetrating transfixing chest trauma, severe shock and respiratory distress. Results: HEMS emergency evacuation under aggressive resuscitation, to a regional trauma center. Further clinical examination, imagistic and complex biomarkers revealed cardiac, lung, spleen and spinal cord contusions. Emergency intervention practiced foreign body extraction, extensive exploration, regulate and surgical treatment of the wound trajectory. Two weeks later, the patient has been discharged from hospital without complications. Conclusions: 1. Patient with opened, penetrating chest trauma should be considered and managed as a life threatening situation but the assessment plan and the investigation strategy required should be extensive in order to identify all visceral both thoracic and abdominal tissues injuries, not only the life-threatening one, as cardiac contusion and spinal cord injuries. 2. Cardiac contusion is not a rare event, but a rare confirmed diagnosis, in association with other sources of shock or hypoxia, the result of traumatic complex of lesions, which include cardiac contusion, could thus impact on survival chances. 3. Air evacuation is, the first intention to assist such a patient in the trauma center.

The iTClamp in the management of prehospital haemorrhage

IntroductionBleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment. MethodsWe have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage. ResultsTen patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7. ConclusionWe conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.

Management of Open Chest Wounds in Tactical Emergency Casualty Care: Application of Vented Versus Nonvented Chest Seals

The 2014 midyear, full meeting of the Committee for Tactical Emergency Combat Care (C-TECC) was hosted by the Johns Hopkins University Center for Law Enforcement Medicine on June 9 and 10 in Baltimore, Maryland. As the C-TECC guidelines are increasingly recognized as the best-practice recommendations for civilian, high-threat, prehospital trauma response, a focused guidelines discussion occurred to develop best-practice recommendations for the management of open chest wounds, specifically regarding the application of vented and nonvented chest seals.

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Unvented chest seals (CSs) are currently recommended for the management of penetrating thoracic injuries in the battlefield. Since no supporting data exist, we compared the efficacy of a preferred unvented with that of a vented CS in a novel swine model of pneumothorax (PTx). An open chest wound was created in the left thorax of spontaneously air-breathing anesthetized pigs (n = 8). A CS was applied over the injury, then tension PTx was induced by incremental air injections (0.2 L) into the pleural cavity via a cannula that was also used to measure intrapleural pressure (IP). Both CS were tested on each pig in series. Tidal volume (V(T)), respiratory rate, IP, heart rate, mean arterial pressure, cardiac output, central venous pressure, pulmonary arterial pressure, venous and peripheral oxygen saturations (SvO2, SpO2) were recorded. Tension PTx was defined as a mean IP equal to or greater than +1 mm Hg plus significant (20-30%) deviation in baseline levels of the previously mentioned parameters and confirmed by chest x-ray study. PaO2 and PaCo2 were also measured. PTx produced immediate breathing difficulty and significant rises in IP and pulmonary arterial pressure and falls in V(T), SpO2, and SvO2. Both CSs returned these parameters to near baseline within 5 minutes of application. After vented CS was applied, serial air injections up to 2 L resulted in no significant change in the previously mentioned parameters. After unvented CS application, progressive deterioration of all respiratory parameters and onset of tension PTx were observed in all subjects after approximately 1.4-L air injection. Both vented and unvented CSs provided immediate improvements in breathing and blood oxygenation in our model of penetrating thoracic trauma. However, in the presence of ongoing intrapleural air accumulation, the unvented CS led to tension PTx, hypoxemia, and possible respiratory arrest, while the vented CS prevented these outcomes.

Necrotizing fasciitis secondary to the insertion of a cardiac pacemaker

We present, to our knowledge, the first reported case of necrotizing fasciitis following insertion of a cardiac permanent pacemaker (PPM). A 91-year-old gentleman was admitted with septic shock under the medical team. He had had a cardiac PPM inserted 10 days prior for complete heart block. He was initially treated by the GP for a postoperative superficial infection with a course of oral antibiotics at home but over the next few days he became systemically unwell. Preadmission, this patient was independent, living with his wife and had no other significant past medical history apart from the heart block. On admission he had suffered a ventricular tachycardia-related cardiac arrest and had been successfully resuscitated. He was subsequently managed in the coronary care unit (CCU) with a diagnosis of systemic sepsis from an infected pacemaker. While in CCU his condition deteriorated and he developed acute renal failure. It was noted that the cellulitis was becoming increasingly widespread around the pacemaker site, and was not responding to the intravenous antibiotics. There was an extremely high suspicion of necrotizing fasciitis, and the plastic surgeons were contacted for a review. The same day, he was expeditiously taken to theatre by the plastic surgical team. Perioperative findings included the presence of murky fluid, oedema of the subcutaneous tissue and necrotic muscle around the pacemaker. This gentleman then underwent a radical debridement of the infected tissues. The infected pacemaker was removed and the patient temporarily externally paced. Microbiology revealed the causative organisms to be Staphylococcus capitis, Streptococcus salivarius and Staphlococcus aureus. The histology from the samples gathered at the time of the procedure was consistent with a diagnosis of necrotizing fasciitis. Following treatment in the intensive care unit, the open chest wound was closed with a split thickness skin graft, five days post-debridement. He had re-implantation of a new PPM on the contralateral (right) side two days later.

Delayed primary versus late secondary wound closure in the treatment of postsurgical sternum osteomyelitis

Sternal osteomyelitis and poststernotomy mediastinitis is a severe and life-threatening complication after the cardiac surgery. The incidence ranges up to 3% with a mortality rate up to 29%. In addition, postoperative infections after sternotomy are associated with prolonged hospital stay, increased healthcare costs and impaired quality of patient life, representing an economic and social burden. The emergence of increasing antimicrobial resistant bacteria augments the importance of postsurgical infections since the antimicrobial choices are becoming limited. Furthermore, the incidence of infection is an indicator for the quality of patient care in the international benchmark studies. Although several therapy strategies are nowadays present in clinical practice, there is a lack of evidence-based surgical consensus for treatment of this surgical complication. In most cases the poststernotomy mediastinitis involves surgical revision with debridement, open dressing and/or vacuum-assisted therapy. After the granulation tissue on open chest wound is achieved, secondary closure and/or reconstruction with vascularized soft tissue flaps, such as omentum or pectoral muscle is performed. It seems there is a need for more effective surgical treatment of poststernotomy wound infections, which may address the prolonged hospitalization and reduce the number of surgical interventions and with this also the perioperative morbidity. In light of this we propose a randomized study comparing new delayed primary closure of the sternum to the secondary vacuum-assisted closure.

The effect and safety after extended use of continuous negative pressure of 75 mmHg over mesh and allodermis graft on open sternal wound from oversized heart transplant in a 3‐month‐old infant*

Negative pressure therapy (NPT) has been reported to be effective in treating infants with open chest wounds. This report further supports its effectiveness by treating a 3-month-old infant with a 12 × 7 cm sized opening in its chest after an oversized heart transplantation. After applying a mesh and allodermis over the defect, 75-mmHg continuous negative pressure was set and used for an extended period of 104 days. The haemodynamic status was evaluated during this period. The wound was closed with secondary intention and it healed well after NPT. There was no haemodynamic instability during the treatment course. The extended use of a continuous negative pressure of 75 mmHg over the mesh and alloderm graft was a reliable and safe option to close the massive defect in the chest of a 3-month-old infant.

Vacuum-assisted Closure for Wound Management

Vacuum-assisted Closure for Wound Management

The trauma patient - critical decision making - when to explore the chest?

The critical decisions regarding thoracotomy for trauma occur soon after the injury, when decisions have to be made that may influence survival or have an impact on morbidity if operation is delayed. Roadside thoracotomy is impractical, and should not be considered; instead, patients should be taken rapidly to the nearest hospital. Endotracheal intubation prior to transport appears to be beneficial, but the application of MAST trousers and the infusion of large volumes of fluid for hypovolaemia before control of haemorrhage offers no advantage and may be hazardous. On the whole, resuscitative thoracotomy is associated with a low salvage rate, especially for the patient sustaining blunt trauma, but may be worthwhile in the patient with penetrating trauma. Urgent, as opposed to immediate thoracotomy, should be undertaken once the patient has been stabilized. This may occur in most patients with penetrating injuries of the heart who survive to reach hospital, those with continuing, significant haemorrhage through chest drains, and those with tracheal, oesophageal and diaphragmatic injuries. Extensive open chest wounds require considerable ingenuity in closure, often with plastic surgical help. Patients with blunt traumatic rupture of the aorta often have multiple injuries, which may also be life threatening. If bleeding into the abdomen is demonstrated, then laparotomy should precede thoracotomy: musculoskeletal injuries and neurological injuries can usually be dealt with after the aortic rupture has been repaired.