Penetrating Chest Injury Research Articles

Traumatic chest injury in children: A single thoracic surgeon's experience in two Nigerian tertiary hospitals.

Background:This study was to determine the extent and outcome of childhood chest injury in Nigeria, and to compare results with that of other literatures.Patients and Methods:A Prospective study of all children under 18 years of age with chest trauma in two tertiary hospitals in Southern Nigeria from January 2012 to December 2014 was reviewed. The aetiology, type, associated injury, mechanism, treatment and outcome were evaluated. The patients were followed up in the clinic. The data were analysed using SPSS version 20.0 with a significant P < 0.05.Results:Thirty-one patients (12.1%) under 18 years of age of 256 chest trauma patients were managed in the thoracic units. The mean age was 9.78 ± 6.77 years and 27 (87.1%) were male. The aetiology in 13 was from falls, 10 from automobile crashes, 3 from gunshots, 4 from stabbing and 1 from abuse. The highest peak of chest injury was on Saturday of the week and April of the year. The pleural collections are as follows: 15 (71.4%) was haemothorax, 4 (19.1%) pneumothorax, 2 (9.5%) haemopneumothorax and 18 patients had lung contusion in combination or alone with the pleural collections. Seven patients who presented >12-h versus 2 who presented <12-h and 6 of children between 0 and 9 years versus 3 at 10-18 years of age had empyema thoracis (P value not significant). One death was recorded.Conclusion:Chest trauma in children is still not common, and blunt chest injury from falls and automobile accidents are more common than penetrating chest injury. Treatment with tube thoracostomy is the major management modality with empyema thoracis as the most common complication.

Posterior Spinal Fiksasyon İçin Kullanılan Lomber Orta Hat İnsizyonundan Torasik Ampiyemin Spontan Drenajı

Empyema is defined as pus in the thoracic cavity due to a pleural space infection caused by bacterial infection following community or hospital- acquired pneumonia or, rarely, blunt or penetrating chest injuries or surgical procedures. Evidence-based guidelines indicated that surgical drainage is more likely to be effective in patients with empyema. The spontaneous drainage of pus through intercostal and paravertebral muscles to the outside is a rare event. In our case, thoracic empyema was drained spontaneously via a lumbar median skin incision for used posterior spinal fixation in an unusual way. Chest and spine injury are found together in the majority of trauma cases. To our knowledge, this case whose thoracic empyema was drained lumbar median skin incision will be first case in the current literature. The surgeons should consider thoracic empyema as a cause of postoperative wound infection or discharge after thoracolumbar fixation.

Emergency anaesthetic management of penetrating thoracic trauma: Combining skill with fortuity.

The results and management of penetrating thoracic trauma are largely dependent upon the extent of injury to internal organs as well as the skills of the attending clinicians. Thoracic trauma in children may be associated with rib fractures, flail chest, soft tissue injury, intrapleural lesions such as haemothorax and pneumothorax, parenchymal lung injuries such as pulmonary contusion and lung laceration as well as mediastinal lesions, including cardiac injury,[1,2] and yet our patient fortuituously had none of these, despite suffering a major, and what could potentially have been a life-threatening accident. The sources of perioperative morbidity and mortality in subjects suffering penetrating thoracic injuries include airway obstruction, respiratory failure and haemorrhage. Clinicians need to be adequately trained to deal with these problems. Trauma mainly affects the younger population and happens to be the most common cause of mortality in patients in the first three decades of life. The technical difficulties encountered during the perioperative management of the patient with severe penetrating thoracic injury are highlighted here.

A retrosternal hematoma presenting as cardiac tamponade after a penetrating chest injury

A 49-year-old man was admitted to our hospital because of an anterior chest wall stab wound. He was conscious but had dyspnea and orthopnea, and his blood pressure was 70/40 mmHg with a pulse rate of 125/minute. The wound was at the right edge of the sternum and sixth intercostal space. Echocardiography was performed, and there were no significant findings in the intrapericardial space. After that, the patient underwent computed tomography (CT) to evaluate the mediastinal and thoracic structures, and the presence of a retrosternal hematoma with cardiac compression was revealed by computed tomographic angiography (Figures 1 and 2). The patient then was immediately taken to the operating room where the hematoma was removed via a median sternotomy and the bleeding from left internal mammary artery was stopped. The pericardium was intact, so it was opened with a small incision to view the intrapericardial space. The pericardial cavity was clean, and the incision was then sutured completely. On the postoperative fourth day, the patient was discharged uneventfully.

Traumatic pseudoaneurysm of the heart

Missile injuries to heart are one of the most severe penetrating chest injuries, and mostly fatal. The presentation in those who survive may be unusual and insidious. Pseudoaneurysms of the heart, usually sequel to myocardial infarction, may rarely present after penetrating cardiac wounds. Their management is a challenging one, and requires the provision of cardiopulmonary bypass. We report a case of ventricular pseudoaneurysm as a consequence of bullet injury, successfully managed in our center.

Management of a pneumopericardium due to penetrating trauma

IntroductionA pneumopericardium presenting after penetrating chest trauma is a rare event. The surgical management of this clinical problem has not been clearly defined. The aim of this study was to document the mode of presentation and to suggest a protocol for management. Patient and methodsA review of a prospectively collected cardiac database of patients presenting to Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 with a pneumopericardium on chest X-ray after penetrating trauma. ResultsThere were 27 patients with a pneumopericardium (mean age 25 years, range 17–36). The mechanism of injury was a stab wound to the chest in 26 patients and a single patient with multiple low velocity gunshot wounds. Six patients (22%) were unstable and required emergency surgery. One of these patients presented with a tension pneumopericardium. Twenty-one patients were initially stable. Two of these (10%) patients later developed a tension pneumopericardium within 24-h and were taken to theatre. The remaining 19 patients were managed with a subxiphoid pericardial window (SPW) at between 24 and 48h post admission. Ten of these 19 patients (52%) were positive for a haemopericardium. Only 4 of the 19 underwent a sternotomy and only two of these had cardiac injuries that had sealed. There were no deaths in this series. ConclusionPatients with a penetrating chest injury with a pneumopericardium who are unstable require emergency surgery. A delayed tension pneumopericardium developed in 10% of patients who were initially stable. It is our recommendation that all stable patients with a pneumopericardium after penetrating chest trauma should undergo a SPW. A sternotomy is not required in stable patients.

Trauma consults on humanitarian surgery trips: A perspective on the Haitian trauma system and the humanitarian’s role

Ubiquitous access to surgical care, especially trauma surgery, is recognized as an essential component of public health. We present two trauma cases—an upper arm machete laceration and a penetrating chest wound—that highlight barriers facing trauma patients in Haiti and describe how it relates to humanitarian surgery trips. An Emory University student–faculty collaborative, partnering with the non-profit Project Medishare (PM) for Haiti since 2008, provides elective and urgent surgical care to the underserved population of the Haitian Central Plateau. This partnership collaborates with a main referral center known for providing quality surgical care at little or no cost. Elective urological and general surgical cases comprise the bulk of the case load but urgent trauma services have been provided when required. Future trauma system initiatives must focus on increasing access to vehicles, telecommunications, and first responders. Our recommendations are reinforced by preliminary results from a trauma needs assessment performed in the Central Plateau and surrounding departments during July 2013. Humanitarian teams can contribute by preparing for emergencies prior to departure and sharing new procedural knowledge with local providers. Supplementing the ability to intercede in emergency surgical situations furthers the goal of short-term surgical trips to diminish indigenous patient morbidity and mortality. We advocate extensive preparation for such situations and increased bidirectional knowledge sharing with local staff.

Penetrating Trauma Resulting in Ventricular Septal Defect

Most ventricular septal defects (VSDs) are congenital. Acquired VSDs are generally due to myocardial infarction. An unusual case of VSD from penetrating trauma is described. In this case, the lack of a hemopericardium at presentation led the treatment team not to pursue cardiac pathology. Once the patient developed heart failure, the diagnosis of a VSD was made. Patients with penetrating chest wounds should undergo echocardiography, as such lesions may not be detected by physical examination or chest exploration.

Pathophysiology and management of blast lung injury

The pattern of lung injuries has gradually changed globally in last two decades from penetrating chest injuries to blast lung injury. This has mainly occurred due to trauma setting in the global war on terror and accidental explosions in confined space in military service conditions. Blast Lung Injury (BLI) presents unique triage, diagnostic and management challenges. A high index of suspicion and timely intervention in these cases is the key to improved outcomes.

Accidental penetrating chest injury with concealed retained wooden stick: A diagnostic dilemma and management.

Accidental penetrating chest injury with concealed retained wooden stick: A diagnostic dilemma and management.

A Straight Left Heart Border: A New Radiological Sign of a Hemopericardium

Detection of a cardiac injury in a stable patient after a penetrating chest injury can be difficult. Ultrasound of the pericardial sac may be associated with a false negative result in the presence of a hemothorax. A filling in of the left heart border inferior to the pulmonary artery, called the straight left heart border (SLHB), is a radiological sign on chest X-ray that we have found to be associated with the finding of a hemopericardium at surgery. The aim of the present study was to determine if this was a reliable and reproducible sign. This was a prospective study of patients with a penetrating chest injury admitted between 1 October 2001 and 28 February 2009, who had no indication for immediate surgery, and were taken to the operating room for creation of a subxiphoid pericardial window (SPW). The chest X-ray was reviewed by a single trauma surgeon prior to surgery. A total of 162 patients with a possible occult cardiac injury underwent creation of a SPW. Fifty-five of the 162 patients (34 %) were noted to have a SLHB on chest X-ray and a hemopericardium confirmed at SPW. The sensitivity of the SLHB sign was 40 %; specificity, 84 %; and positive predictive value, 89 %. (p = 0.005, Odds ratio 3.48, lower 1.41, upper 8.62). The straight left heart border is a newly described radiological sign that was highly significant in predicting the presence of a hemopericardium and should alert the clinician to a possible occult cardiac injury.

Post-traumatic interventricular communication as a life-threatening late complication of a penetrating chest injury

A 65-year old woman underwent an exploratory right thoracotomy for haemopneumothorax (Fig. 1) after penetrating chest trauma (double-stabbing). Operative findings included a 1-cm pericardial lesion associated with an apparently superficial wound of the right ventricle (without significant signs of active bleeding and treated with direct suture) and moderate intercostal bleeding. Respiratory failure occurred on the fourth postoperative day. CT scan showed an interventricular communication (Fig. 2) and the patient underwent successful surgical repair (endocardial patch technique) of this defect under total cardiopulmonary bypass.

Have patient pathways for penetrating chest injuries improved since designation as a London major trauma centre?

Results 25 cases from April, May and June 2010 (100% male, mean age 28.6 years) and 28 cases from April, May and June 2011 (100% male, mean age 24.1 years) were indentified. In 2010, mean time to CXR was 18.86 minutes, 95% CI (12.97, 24.75) and mean time to CT was 93.10 minutes (61.27, 124.93). In 40% of cases use of eFAST was documented. In total, 91.3% underwent CT scanning of the thorax. In February 2011, a Standard Operating Procedure (SOP) was introduced along with pre-registration of patients prior to arrival, use of a designated trauma CT scanner and increased training of eFAST. In 2011, mean time to CXR was 10.45 minutes, 95% CI (7.55, 13.35) and mean time to CT was 46.94 minutes, 95% CI (26.36, 67.52). In 54% of cases use of eFAST was documented. In total, 60.7% of cases underwent CT scanning of the thorax. Comparing this data over time, both time to CXR (p=0.012) and time to CT (p= 0.000024) have significantly decreased along with increased utilisation of eFAST and reduced use of CT scanning in accordance with the SOP.

Penetrating Chest Injury in the Setting of a Hemothorax: Should Pericardial Windows Replace Echocardiograms?

Penetrating Chest Injury in the Setting of a Hemothorax: Should Pericardial Windows Replace Echocardiograms?

Penetrating chest injury: A miraculous life salvage

An unusual penetrating chest injury was caused by high velocity road traffic accident. An 18-year-old had a four wheeler accident and was brought in emergency department with a 'bamboo' stick on the left side chest exiting through back. After the stabilization of vital parameters, an inter-costal tube drainage was done on the left side. <br>Except the minor brochopleural fistula which healed by 10 ^th day, his recovery was uneventful. The outcome was consistent with current aggressive management of penetrating chest injuries. Management of penetrating chest injury involving pulmonary trauma is based on three principles. One is stabilization of hemodynamics of patient with proper clinical evaluation. Second, a mere intercostal tube drainage sufficient for majority of the cases. Third, post-operative active as well as passive physiotherapy is necessary for speedy recovery.

Phrenic nerve injury and diaphragmatic paralysis following pacemaker pulse generator replacement

Diaphragmatic paralysis (DP) is a common condition. It can be unilateral or bilateral and the diagnosis is usually based on a clinical and radiological findings. Bilateral diaphragmatic paralysis is usually symptomatic with dyspnea and acute respiratory failure while unilateral diaphragmatic paralysis is typically asymptomatic and when present, symptoms usually depend on the presence of underlying pulmonary or neurologic disease. DP can be the result of various chest conditions that affect the phrenic nerve such as tumors, vascular abnormalities or traumatic incidents during surgery as well as blunt or penetrating chest or neck injuries. We report a unique case of phrenic nerve injury and unilateral diaphragmatic paralysis secondary to pacemaker pulse generator replacement that was successfully treated with diaphragmatic plication.

Phrenic Nerve Injury and Diaphragmatic Paralysis Following Pacemaker Pulse Generator Replacement

Diaphragmatic paralysis (DP) is a common condition. It can be unilateral or bilateral and the diagnosis is usually based on a clinical and radiological findings. Bilateral diaphragmatic paralysis is usually symptomatic with dyspnea and acute respiratory failure while unilateral diaphragmatic paralysis is typically asymptomatic and when present, symptoms usually depend on the presence of underlying pulmonary or neurologic disease. DP can be the result of various chest conditions that affect the phrenic nerve such as tumors, vascular abnormalities or traumatic incidents during surgery as well as blunt or penetrating chest or neck injuries. We report a unique case of phrenic nerve injury and unilateral diaphragmatic paralysis secondary to pacemaker pulse generator replacement that was successfully treated with diaphragmatic plication.

Impalement Injury to The Heart

Cardiac impalement injury is rare and one of the most severe penetrating chest injuries, often fatal. The management of penetrating cardiac injuries is a challenging one. The success in management of impaling cardiac trauma requires stabilization of the impaling object, expeditious transfer to a facility for open heart surgery, rapid imaging, access to blood and blood products and a ready surgical team. We report a case of impalement injury to the heart by a stick, transfixing the right ventricle and its successful treatment.

Intercostal catheter insertion: are we really doing well?

Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes. Prospective audit of all ICC in trauma patients at a level 1 trauma centre for over 12 months. Exclusions were pigtail catheters and ICC inserted during thoracic surgery. Errors were identified from patient examination and chest imaging; they were defined as insertional, positional, incorrect size (<28 French) and lack of antibiotic prophylaxis. Ongoing complications unrelated to an error in technique, for example blocked tube, were not analysed. Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 ± 20 years, mean injury severity score 27 ± 13, mean abbreviated injury scale chest 3.8 ± 0.72. 86% were blunt trauma and 14% penetrating chest injuries. Thirty-six errors in technique occurred in 33 ICC insertions (38%). The most common errors were absence of prophylactic antibiotics (13%), ICC too far out (9%), kinked (6%) and wrong-sized ICC (5%). Emergency had a significantly greater frequency of errors than other specialties (67%, relative risk 2.11, P= 0.002). The majority of ICC were inserted by registrars, and registrars made a greater number of errors than fellows or consultants (relative risk 2.00, P= 0.02). This study identified a large number of preventable errors for ICC insertion in trauma patients. Standardized institutional credentialing systems may be required to ensure adequate proficiency of trainees performing this procedure.

A Pneumomediastinum with Diffuse Subcutaneous Emphysema

A 65-year-old man presented to the Emergency Department with facial angioedema. It occurred just after an intramuscular morphine injection in the shoulder for a minor chest trauma from falling off a chair. On physical examination, he had right chest pain, a pulse of 90 beats/min, blood pressure of 140/80 mm Hg, respiratory rate of 35 breaths/min, and room air oxygen saturation of 88%. Diffuse wheezes were detectable in both lungs. He was provided with supplemental oxygen, salbutamol aerosol, and corticosteroid treatment. After initial stabilization, subcutaneous emphysema developed suddenly over his chest. Chest radiography revealed a right lucency, some mediastinal radiolucent streaks, and subcutaneous emphysema (Figure 1). Chest computed tomography scan with intravenous contrast confirmed the right pneumothorax and the pneumomediastinum (Figure 2, Figure 3), and revealed a rib fracture (Figure 4). A chest drain was inserted and the patient’s condition improved.Figure 2Chest computed tomography scan (tissue window). Right pneumothorax (arrow) and pneumomediastinum (arrow) are visible.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Chest computed tomography scan (tissue window) reveals right and left pneumothoraces and pneumomediastinum with dissection of bronchovascular sheaths (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Chest computed tomography scan (bone window) shows a rib fracture (arrow).Used with permission of Emilie Dehours, MD, Department of Emergency Medicine, Purpan, Toulouse, France.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The term pneumothorax was first coined in 1803 by Itard, and its clinical features were described by Laennec in 1819. More than half of pneumothoraces are traumatic (accidental or iatrogenic); the others occur without any preceding trauma and are labeled spontaneous (1Schramel F.M.N.H. Postmus P.E. Vanderschueren R.G.J.R.A. Current aspects of spontaneous pneumothorax.Eur Respir J. 1997; 10: 1372-1379Crossref PubMed Scopus (257) Google Scholar). Traumatic pneumothoraces result from penetrating or nonpenetrating chest injuries (2Gupta D. Hansell A. Nichols T. et al.Epidemiology of pneumothorax in England.Thorax. 2000; 55: 666-671Crossref PubMed Scopus (259) Google Scholar). It is noteworthy that, in the literature, there is a strong association between rib fractures and pneumothoraces (3Bridges K.G. Welch G. Silver M. et al.CT detection of occult pneumothorax in multiple trauma patients.J Emerg Med. 1993; 11: 179-186Abstract Full Text PDF PubMed Scopus (90) Google Scholar). On the other hand, pneumomediastinum, reported in 1939 by Hamman, is an uncommon clinical entity (4Chalumeau M. Clainche L. Sayeg N. et al.Spontaneous pneumomediastinum in children.Pediatr Pulmunol. 2001; 31: 67-75Crossref PubMed Scopus (147) Google Scholar). The first described pneumomediastinum by Laennec in 1819 was a consequence of traumatic injury. The most widely accepted explanation for the development of pneumomediastium is a sudden rupture of distended alveoli under high-pressure gradient between the alveoli and the surrounding interstitial space. The free air then dissects from the ruptured alveoli along the bronchovascular sheaths toward the mediastinum. This sequence of events is known as the “Macklin Effect” (5Macklin M.T. Macklin C.C. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions.Medicine. 1994; 23: 281-352Crossref Scopus (604) Google Scholar). Gas can also escape retroperitoneally through periaortic and periesophageal planes (6Zylak C.M. Standen J.R. Barnes G.R. et al.Pneumomediastinum revisited.Radiographics. 2000; 20: 1043-1057Crossref PubMed Scopus (164) Google Scholar). As a result, the air within the mediastinum can further dissect through these planes, causing pneumopericardium, pneumoretroperitoneum, and pneumoperitoneum. As a consequence of our finding, early incorporation of a routine chest computed tomography scan in all patients with rib fractures might be required to successfully diagnose pneumothoraces and pneumomediastinum.