Penetrating Thoracic Injuries Research Articles

Penetrating combat-related thoracic trauma (review)

Objective — to study in detail the mechanisms and to investigate the imaging manifestations of combat-related penetrating thoracic injuries.
 Materials and methods. To perform the work, a literature search was provided according to the criterion «Thoracic penetrating combat-related trauma». 32 literary sources were selected for this request. Frag­ments of the clinical experience described in the literature according to the selected sources were illustrated by our own clinical cases of patients who were treated in Kharkiv medical institutions in 2022 for penetrating combat-related thoracic injuries.
 Results and discussion. Among victims who received chest injuries, polytrauma was most often diagnosed, complicated by several mechanisms of injury associated with penetrating, blunt, and explosive injuries. Pneumothorax and pulmonary contusion were the most common chest injuries. Thoracic injuries, thoracic vascular injuries, and lung ruptures were associated with the highest mortality rates, whereas pulmonary contusions, pneumothorax, and chest wall injuries were associated with relatively lower mortality rates. Chest X-ray is the first-line imaging method during the initial assessment of thoracic trauma in combat and non-combat situations. Such an examination is particularly important in polytrauma situations where multiple fatal injuries can be rapidly diagnosed in order to rapidly triage and include such an injury in the initial evaluation. Tension pneumothorax, large hemothorax, chest fragmentation, and some other lesions can be quickly diagnosed with a portable chest X-ray. Computed tomography (CT) of the chest is an important component of the comprehensive trauma evaluation, which allows to diagnose life-threatening injuries in hemodynamically stable patients with suspected multiple injuries not identified on chest X-ray. Chest CT detects 20 % more pathologies compared to chest X-ray.
 Conclusions. Combat-related thoracic trauma continues to be a significant contributor to the mortality rates of those injured in military operations. A clear injury pattern and atypical imaging manifestations of thoracic trauma are important to recognize at an early stage because of the acuteness of this category of patients and the impact of an accurate diagnosis on clinical management. Chest X-ray remains the main diagnostic tool. However, in modern and well-equipped institutions, chest CT, video-assisted thoracoscopy, and ultrasound scanning of the abdominal and chest cavity play an important role in the diagnosis of thoracic trauma. Quick and high-quality diagnosis and treatment are possible only in direct cooperation between surgeons and radiologists.

Pediatric penetrating thoracic trauma: Examining the impact of trauma center designation and penetrating trauma volume on outcomes

IntroductionWe analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI). MethodsPTI patients <18 years were identified from the National Trauma Data Bank (2013–2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance. ResultsWe identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers. DiscussionAdult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes. Level of evidenceLevel III.

Management of penetrating thoracic injury sustained during a mountain-biking accident

Trauma is a common phenomenon in South Africa, with a large proportion of patients suffering from penetrating chest injuries. Occasionally atypical penetrating thoracic injuries require surgical intervention with special considerations. We describe the management of a 15-year-old boy who presented to our trauma unit with a large diameter branch penetrating his left chest above the left clavicle and with the tip lodged in the mediastinum between the great vessels. Pulsatile movement of the foreign body was clearly visible and required careful consideration for the optimal approach and possible complications that may arise. The tract and location of the foreign body made the approach and management of this patient unique and a valuable learning opportunity. A high lateral thoracotomy was done, and the object removed under direct vision. It yielded excellent exposure and proved to be a good alternative approach for certain atypical cases. The boy made a full recovery with no long-term complications.

Thoracic trauma – principals of surgical management

Thoracic trauma continues to be a significant surgical problem. It is estimated that 25% of trauma-related deaths are due to penetrating and blunt thoracic injuries. Principals of surgical management of specific thoracic injuries like: tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, cardiac injuries, ruptures of the aorta, tracheobronchial tree lesions, oesophageal and diaphragmatic injuries have been reviewed. Awareness of the potential for deterioration and early correct identification of life threatening thoracic injuries are the keys to successful management. Good outcomes in the management of thoracic injuries depend on rapid transport of the injured patient to the hospital, effective diagnostic and therapeutic measures and an aggressive involvement of an experienced surgical team, optimally in the operating theatre. Successful management of these injuries depends on effective prioritisation of procedures based on the ABC principals combined with a rapid diagnosis of severe injuries and aggressive surgical treatment of life-threatening lesions following penetrating and blunt trauma. Rapid decompression of tension pneumothorax and emergency thoracotomy, especially in patients following penetrating thoracic trauma may result in good outcomes. Effective management of severe thoracic injuries requires an integrated approach and cooperation of a multidisciplinary trauma team, including experienced thoracic and cardiac surgeons.

Evaluation of factors affecting prognosis in penetrating thoracic injuries.

This study aims to investigate the prognostic factors affecting survival and clinical outcomes in patients exposed to pediatric penetrating thoracic injury. A t otal o f 2 67 p ediatric p enetrating t horacic injury patients (217 males, 50 females; mean age 10.8 years; range, 3 to 17 years) who were treated at our hospital during the recent 20 years were analyzed retrospectively. Penetrating thoracic injuries were divided into three groups: incisive/stabbing injuries, gunshot injuries, explosive injuries. Patients" age, gender, New Injury Severity Score, injury type, injuries accompanying thoracic trauma, types of treatment applied, length of hospital stay, and morbidity and mortality outcomes were examined. Their prognostic characteristics were compared to their injury types, New Injury Severity Scores, lengths of hospital stay and complications. Of the patients, 103 were exposed to gunshot injuries, 128 to incisive/stabbing injuries, and 36 to explosive injuries. Of the penetrating thoracic injuries, while 211 (79%) were isolated injuries, 56 (21%) were accompanying non-thoracic injuries. Mean New Injury Severity Score was 13±10. Of the patients, 50 (18.6%) were treated with medical therapy alone, 199 (74.5%) with tube thoracostomy, and 18 (6.7%) with thoracotomy. Fiftyone patients (19%) developed complications. Length of hospital was 9±2.7 days. Twenty-one patients (7.9%) died. New Injury Severity Scores, rates of combined injuries, complications, length of hospital stay, and mortality were higher in explosive injuries (p<0.05). Pediatric penetrating thoracic injuries may be observed in all age groups in children, the most severe type being explosive injuries. Prognostic factors may vary according to injury type, complications, treatment approach, and presence of accompanying non-thoracic injuries.

Surgical management of penetrating thoracic injuries during the Paris attacks on 13 November 2015.

The Paris terrorist attacks on 13 November 2015 caused 482 casualties, including 130 deaths and 352 wounded. Facing these multisite terrorist attacks, Parisian public and military hospitals simultaneously managed numerous patients with penetrating thoracic injuries. The aim of this study was to analyse this cohort, the injury patterns, and assess the results of this mobilization. The clinical records of all patients admitted to Parisian public and military hospitals with a penetrating thoracic injury related to the Paris 13 November terrorist attacks were reviewed. The study group included 25 patients (7% of the casualties) with a mean age of 34 ± 8 years and a majority of gunshot wounds ( n = 20, 80%). Most patients presented with severe thoracic injury (Abbreviated Injury Score Thorax 3.3 ± 1.2), and also associated non-thoracic injuries in 21 cases (84%). The mean Injury Severity Score was 26.8 ± 9.4. Eight patients (32%) were managed with chest tube insertion and 17 (68%) required thoracic surgery. Lung resection, diaphragmatic repair, and lung suture were performed in 6 (36%), 6 (35%), and 5 cases (29%), respectively. Extra-thoracic surgical procedures were performed in 16 patients, mostly for injuries to the extremities. Postoperative mortality was 12% ( n = 3) and postoperative morbidity was 60% ( n = 15). The coordination of Parisian military and civilian hospitals allowed the surgical management of 25 patients. The mortality is high but consistent with what has been reported in previous series. The current times expose us to the threat of new terrorist attacks and require that the medical community be prepared.

Emergency Thoracotomy in a Swedish Setting: A Consecutive Series of 45 Patients from a Scandinavian Trauma Hospital

Background: Emergency thoracotomy (ET) has previously been studied and evaluated in an American and African perspective. The mechanism of injury (MOI) varies between different parts of the world. In the Northern European setting, blunt trauma is the most common MOI. Regarding penetrating thoracic injuries stab wounds compromises the majority whereas gunshot wounds (GSW) are relatively scarce. The aim of this study was to describe the situation at a Scandinavian Trauma Hospital. Method: This study was a retrospective case series involving all patients who underwent an ET between 2004 and 2011 at a single centre. Patients were identified and data collection of demographics, trauma scores and physiological values were retrieved from hospital charts and trauma registry. Statistical analyses were performed. Results: A total of 45 ET patients were identified. The patients were predominately male (82%), and severely injured with median ISS of 48. The overall survival rate was 31%. Blunt trauma accounted for 60% of the patients. Survival following penetrating thoracic trauma had a 50% survival rate, whereas blunt trauma had a 19% survival rate. Conclusion: The injury pattern preceding ET is different between America and Europe. Blunt trauma accounts for the majority of cases. Penetrating trauma is mostly caused by stab wounds which carry a better prognosis than gunshot wounds (GSW). There is clearly a value in performing ET for selected cases following penetrating thoracic violence. Most of the surviving cases of thoracotomy for blunt trauma were for aortic cross clamping to control abdominal bleeding. Isolated blunt trauma to the chest carried a dismal prognosis.

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.

Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations

Studies reporting on penetrating thoracic trauma in the pediatric population have been limited by small numbers and implied differences with the adult population. Our objectives were to report on a large cohort of pediatric patients presenting with penetrating thoracic trauma and to determine age-related impacts on management and outcome through comparison with an adult cohort. A Level I trauma center registry was queried between 2006 and 2012. All patients presenting with penetrating thoracic trauma were identified. Patient demographics, injury mechanism, injury severity, admission physiology, and outcome were recorded. Patients were compared, and outcomes were analyzed based on age at presentation, with patients 17 years or younger defining our pediatric cohort. A total of 1,423 patients with penetrating thoracic trauma were admitted during the study period. Two hundred twenty patients (15.5%) were pediatric, with 205 being adolescents (13-17 years) and 15 being children (≤ 12 years). In terms of management for the pediatric population, tube thoracostomy alone was needed in 32.7% (72 of 220), whereas operative thoracic exploration was performed in 20.0% (44 of 220). Overall mortality was 13.6% (30 of 220). There was no significant difference between the pediatric and adult population with regard to injury mechanism or severity, need for therapeutic intervention, operative approach, use of emergency department thoracotomy, or outcome. Stepwise logistic regression failed to identify age as a predictor for the need for either therapeutic intervention or mortality between the two age groups as a whole. However, subgroup analysis revealed that being 12 years or younger (odds ratio, 3.84; 95% confidence interval, 1.29-11.4) was an independent predictor of mortality. Management of traumatic penetrating thoracic injuries in terms of the need for therapeutic intervention and operative approach was similar between the adult and pediatric populations. Mortality from penetrating thoracic trauma can be predicted based on injury severity, the use of emergency department thoracotomy, and admission physiology for adolescents and adults. Children may be at increased risk for poor outcome independent of injury severity. Epidemiologic study, level III.

Analysis of cardiac and pulmonary injuries resulting from an experimental penetrating thoracic injury.

This study was planned to analyze the internal and external anatomical findings of cardiac injuries and the presence of accompanying pulmonary injuries in intentionally inflicted thoracic injuries to swine models. We inflicted a penetrating heart injury in six suis domesticus female swine models. Two cardiac injuries, one on the left paratracheal of fourth intercostal space (ICS) and the other on the right side were inflicted on each model by the same researcher using a 20-cm long scalpel. All animals were then sacrificed for morphological evaluation. After strikes to the left fourth ICS, external evaluation showed that 50% of the subjects suffered a single laceration and that 33% suffered multiple lacerations. Internal evaluation showed additional intracardiac injuries in all five subjects. However, the subject that suffered a single laceration on the outer surface of the heart had multiple internal injuries while another subject that had multiple outer lacerations had only one intracardiac injury. Only three subjects suffered cardiac injuries and only two out of those three with pulmonary injuries after right fourth intercostal intrusions. This experiment has shown that external evaluation of the heart tissue may not alone be sufficient to determine the extent of cardiac injuries and accompanying pulmonary injuries caused by penetrating thoracic injuries.

Autologous transfusion in a patient with life threatening traumatic haemothorax: Case Report.

Penetrating thoracic injuries frequently presents a challenge to the clinicians. The situation may become more deleterious owing to the unavailability of adequate blood of required group. We discuss the acute management of a patient with life threatening traumatic haemothorax following penetrating thoracic injury. In this patient, autologous transfusion of patient blood collected in chest drain was performed during intraoperative period using an indigenous technique with successful outcome. DOI: http://dx.doi.org/10.3329/bjms.v13i1.14146 Bangladesh Journal of Medical Science Vol. 13 No. 01 January2014: 76-79

Follow-up After Asymptomatic Penetrating Thoracic Injury: 3 Hours is Enough

Patients with asymptomatic penetrating thoracic injuries routinely undergo chest radiographs (CXRs) upon emergency department (ED) arrival, and then 6 hours later to exclude delayed pneumothorax (PTX) or hemothorax (HTX). Although previous reports indicate that up to 12% (mean, 3%) of asymptomatic penetrating thoracic injuries are complicated by delayed PTX or HTX, we hypothesized that these events would be detectable after only 3 hours of observation. The purpose of this study was to compare the incidence of delayed thoracic injury at 3 hours and 6 hours using standard CXR. A prospective trial of asymptomatic patients with penetrating thoracic injuries was conducted during 36 months. CXRs were performed upon arrival (supine, AP), and at 3 hours (upright, PA/lateral) and 6 hours (upright, PA/lateral). Patients with either injuries detected on initial CXR or cardiopulmonary symptoms were excluded. Findings from 3 hour and 6 hour CXRs were compared. Assuming a delayed PTX or HTX rate of 3%, the probability of detecting at least one delayed event between 3 hours and 6 hours in 100 patients is 95.25%. Of 648 patients with penetrating thoracic injuries, 100 patients both met inclusion criteria and completed the study. Patients were predominantly young (32.5 years +/- 13.3 years [mean +/- SD]) men (75% men) with stab wounds (75% stab wounds, 25% gunshot wounds). The mean length of stay for patients discharged from the ED was 8.8 hours +/- 2.6 hours. Although two patients developed a PTX between arrival and 3 hours, none developed after 3 hours. Patient charges, hospital costs, and radiation exposure were calculated for patients in our proposed study protocol, totaling $2802, $189, and 0.08 mSv, respectively. No patient in our study population developed a delayed PTX or HTX after 3 hours. Our results suggest that shortening the observation period after asymptomatic penetrating thoracic injuries to 3 hours is safe, cost-effective, minimizes radiation exposure, and may help relieve congested urban EDs.

Penetrating thoracoabdominal injuries.

Abstract Twenty-three cases of penetrating thoracoabdominal injury are reviewed. Abdominal pain, tenderness and rigidity were found to be the most constant indicators of diaphragmatic penetration in these injuries (65 per cent). These features may occur as referred phenomena of purely thoracic injuries and persist as a result of the presence of an intercostal drainage tube used in the treatment of such injuries. There may be no abdominal signs in injuries of the diaphragm unaccompanied by any visceral damage or in injuries confined to the lesser sac. A high index of suspicion in the presence of a wound over the lower half of the chest is necessary to detect these lesions. Negative radiological findings do not exclude a diaphragmatic injury. The thoracic component of a penetrating thoracoabdominal injury can usually be treated conservatively by aspiration or drainage of the pleural space, but laparotomy is advised for the repair of the abdominal viscera. The need for thoracotomy should be determined by the merits of the thoracic injury or the desirability of pleural toilet. The intra-abdominal injury may then be dealt with through the diaphragm. There is a greater tendency to pleural infection in thoracoabdominal injuries than in simple penetrating thoracic injuries, which is attributable to contamination by intestinal contents through the diaphragmatic tear. The mortality in this series was due to the abdominal injuries, the early recognition and treatment of which would have improved results.

Penetrating Thoracic Injuries

One hundred patients who were in extremis and required Emergency Room Thoracotomy (ERT) after sustaining penetrating thoracic injuries were analyzed to compare the results of attempted stabilization in the field (n = 51) with those who had immediate transportation (n = 49). The clinical status of the patients in the field and in the E.R. was quantified by Trauma Score (TS) as well as Physiologic Index (PI), ranging in severity from 20 (clinically dead) to 5 (stable). The anatomic injury severity was expressed by Penetrating Trauma Index (PTI). Survival was analyzed according to the type of injuries: noncardiac and cardiac. The overall survival was 10%. There was only one survivor with noncardiac injuries. Sixty-nine patients had cardiac penetration, 33 in Group I (stabilization) and 36 in Group II (immediate transport). Despite attempts at stabilization, none of the patients in Group I showed an improvement in clinical status from the scene to the emergency room. There were a higher number of patients arriving at the E.R. with signs of life in Group II compared to Group I. In Group II patients, survival was significantly improved overall (p = 0.01), in patients with signs of life on arrival at the hospital (p = 0.02) and in patients with isolated right ventricular wounds (p = 0.01) compared with Group I. The anatomic injury severity (PTI) as well as the mode of injury in the two groups was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of air embolism in blunt and penetrating thoracic trauma

The charts of 61 patients treated from 1970 through 1981 were reviewed to determine the clinical outcome after treatment of air embolism from blunt (15 patients) and penetrating (21 gunshot and 25 stabbing) thoracic injuries. The diagnosis of air embolism was confirmed by the presence of air in the coronary arteries (57%), air aspirated from the heart (30%) or major artery (10%), or Doppler findings (3%). All patients were in shock or cardiac arrest, and in 36% of these patients there were early signs of hemoptysis or unexpected arrest after intubation and positive-pressure ventilation. Successful management included (1) early thoracotomy for diagnosis as well as for specific treatment, (2) hilar cross-clamping for control of bronchovenous communication, (3) maintenance of perfusion pressures with fluids, vasopressors, or aortic cross-clamping, and (4) prompt correction of the embolic source, usually a lung resection. The overall survival rate was 44%, which correlated with the mechanism of injury, with associated nonthoracic injuries, and with the occurrence of arrest in a controlled setting. We conclude that (1) air embolism can insidiously occur even in blunt trauma; (2) suspicion should be high with hemoptysis or unexpected arrest; and (3) successful treatment includes immediate thoracotomy for diagnosis, resuscitation, and prompt control of the bronchovenous communication.

Traumatic right coronary arterial-right atrial fistula

A healthy 25 year old man presented with a machinery murmur and a history of a penetrating thoracic injury. Hemodynamic and angiographie evaluation demonstrated a fistula from the right coronary artery to the right atrium that was later successfully repaired. This case and similar reported cases indicate that fistula formation is a late complication of penetrating thoracic injuries. The onset of the murmur occurs with enlargement of the fistula and typically is delayed for several weeks to months after the initial injury.

Penetrating Chest Injuries in Children

A consecutive series of 14 Vietnamese children aged 2 to 16 years with war-related penetrating thoracic injuries is presented. The children were treated by the author aboard U.S. Navy hospital ships in a one-year period from October, 1969, to September, 1970. Seven had sucking chest wounds and 9 had intrapulmonary hematomas on admission. Three had associated abdominal penetration, and 2 had craniocerebral injury. Three had sustained gunshot wounds, and 11 had missile injuries. Emphasis is placed upon resuscitation using large central venous catheters; rapid pulmonary reexpansion using large-bore polyvinyl chest tubes; debridement and primary closure of chest wounds; concurrent treatment of associated injuries; and vigorous treatment for and prevention of pulmonary complications. Ten children had an uncomplicated recovery from their thoracic injuries; 4 had chest complications. There were no deaths in this series, nor any chest wound infections, residual bronchopleural fistulas, clotted hemothorax, empyema, or excavating hematoma.