Pulmonary Contusion Research Articles

A case report on a 62-year male with Electrocution injury due to lighting causing Ischemic Rhabdomyolysis with lung contusion with respiratory failure

Introduction : A lightning strike is an uncommon, fatal natural occurrence that causes significant problems to various organ systems. MI, cardiac contusion, cutaneous burns, pulmonary issues, neurological disorders, abrupt renal failure, and death are the complications of lighting injury. Rapid disintegration of injured or damaged skeletal muscles is a complex medical disorder known as rhabdomyolysis. Here, we’ll talk about the treatment and prognosis in the case of a 62-year-old male who suffered an electrocution injury from lightning that resulted in rhabdomyolysis, lung contusion, and respiratory failure. Present complaints and investigation : A case of a 62-year-old male was registered to our tertiary care rural hospital in casualty with the chief complaints of lightening injury, loss of consciousness for 15 minutes, injury to the right side of the forehead, above the right eyebrow, cough with expectoration since two days, difficulty in swallowing since two days. Now he has come here for further treatment. The main diagnosis, therapeutic intervention, and outcome : After all necessary assessments the doctor found the diagnosed electrocution injury due to lightning causing rhabdomyolysis with lung contusion and respiratory failure. The patient was treated with IV fluids, inj. optineuron, inj. meropenem 1 gm, inj. Tigecycline 50mg IV, inj. pantop 40mg inj. Collision three ml IV freq. 8 hrs also provide the Nebulization 4 hourly. All the treatment was given, but the result was unsatisfactory. Conclusion : He responded to all the medication and the doctor’s treatment, but his recovery was poor.

Successful Management of a Polytrauma with Open Complex Pelvic Fracture

Abstract Pelvic fractures frequently result from powerful external forces and carry a high risk of concurrent injuries. In these patients, fatalities are often caused by associated injuries. Pelvic fractures cause substantial morbidity and can lead to long-term impairment in physical functioning, as well as difficulties with daily activities and negative psychological health. Surgical intervention is necessary for treating unstable pelvic fractures, which may involve isolated posterior or combined posterior and anterior fixation utilizing screws and plates to restore anatomical alignment and promote natural healing. A 19-year-old female road traffic accident victim in hemorrhagic shock was hemodynamically stabilized and investigated for associated injuries. She was diagnosed with bilateral sacroiliac joint dislocations, bilateral superior and inferior pubic rami fractures and crescent fracture of the right iliac wing, Grade III liver injury, Grade III splenic infarction and hemoperitoneum, lung contusion, and bilateral hemothorax with multiple rib fractures, fracture of the transverse process of L4 and L5 vertebrae. A secondary survey revealed a right sciatic nerve injury, admitted to intensive care and managed by a multidisciplinary approach. Abdomen and thorax injuries were managed conservatively, and meanwhile, the pelvic fracture was stabilized by a damage control protocol, and definitive surgical intervention includes iliac crest wound debridement and pelvic ring open reduction and internal fixation by the Modified Stoppa approach. Abdomen and chest injuries were managed conservatively. Monthly regular follow-up was the first 6 months, was able to walk and sit comfortably at the end of 4 months, and was able to resume her normal routine work and job at 6 months without any pain and limitation of movements. It is essential to promptly identify and assess the injuries and implement appropriate perioperative management by a multidisciplinary team. Temporary stabilization of fracture followed by the management of associated injuries and delayed definite fixation yields the best result in polytrauma patients with pelvic fracture.

Occult pneumothorax in patients with blunted polytrauma: an experience of Tanta University Hospitals

Abstract Aims The objective of this study was to retrospectively evaluate the incidence, management, and outcome of occult pneumothorax (OPTX) in patients with blunt chest trauma (BCT). Settings and design A retrospective observational study was performed. Patients and methods Over 9 years, cases with BCT were identified retrospectively from the database between 2012 and 2021. Data were evaluated and compared based on the first management (conservative vs. intercostal tube). Results Of the 2113 cases, 51 (2.4%) admitted with BCT during the study period were found to have OPTX. The mean age of patients was 37 ± 6.58 years, and there was a male predominance (78.43%). Intercostal tube intervention was done in 29 (53.8%) cases, and conservative management was done in 22 (43.13%) cases. Cases that needed tube thoracostomy had significantly higher rates of lung and chest contusions and high Abbreviated Injury Scale compared with those who were treated conservatively. However, pneumonia, rib fracture, hospital length of stay, and ventilatory days were insignificantly different between both groups. Overall mortality was 9.8%. Conclusions In cases with BCT that did not require major interventions or needed to be mechanically ventilated, their OPTX can be safely managed conservatively.

Post-Traumatic Pulmonary Pneumatoceles: A Case Report

Road accidents are the main cause of serious injuries worldwide, accounting for over 10% of trauma cases resulting in death or significant physical impairment. Thoracic injuries, on the other hand, are responsible for a quarter of all trauma-related deaths. In such cases, pneumothorax is the most common thoracic injury, affecting 30 to 40% of patients with thoracic trauma. This injury occurs twice as often in closed traumas as in penetrating traumas. However, post-traumatic pulmonary pneumatocele is a very rare condition that occurs mostly in children and young adults. It’s often a sequelae of acute pneumonia or barotrauma resulting from alveolar hyperpressure in the context of closed glottis trauma.
 Recognizing these injuries quickly can save lives, whether the patient is outside or in a modern intensive care unit.
 The reported case is an 8-year-old female child with no medical history, no delayed growth or development, who was involved in a public road accident with a thoracic impact. She presented with hemoptysis and chest pain, and a thoracic CT scan revealed bilateral pulmonary parenchymal contusions predominantly on the right, with post-traumatic pneumatoceles on the right side and a right pneumothorax blade, with good progress under surveillance, oxygen therapy, and prophylactic antibiotic treatment.

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.

High positive end-expiratory pressure ventilation mitigates the progression from unilateral pulmonary contusion to ARDS: An animal study.

Pulmonary contusion (PC) is common in severely traumatized patients and can lead to respiratory failure requiring mechanical ventilation (MV). Ventilator-induced lung injury (VILI) might aggravate lung damage. Despite underrepresentation of trauma patients in trials on lung-protective MV, results are extrapolated to these patients, potentially disregarding important pathophysiological differences. Three MV protocols with different positive end-expiratory pressure (PEEP) levels: ARDSnetwork lower PEEP (ARDSnet-low), ARDSnetwork higher PEEP (ARDSnet-high), and open lung concept (OLC) were applied in swine for 24 hours following PC. Gas exchange, lung mechanics, quantitative computed tomography, and diffuse alveolar damage (DAD) score were analyzed. Results are given as median (interquartile range) at 24 hours. Statistical testing was performed using general linear models (group effect) over all measurement points and pairwise Mann-Whitney U tests for DAD. There were significant differences between groups: PEEP ( p < 0.0001) ARDSnet-low (8 [8-10] cmH 2 O), ARDSnet-high (12 [12-12] cmH 2 O), OLC (21 [20-22] cmH 2 O). The fraction of arterial partial pressure of oxygen and inspired oxygen fraction ( p = 0.0016) was lowest in ARDSnet-low (78 (73-111) mm Hg) compared with ARDSnet-high (375 (365-423) mm Hg) and OLC (499 (430-523) mm Hg). The end-expiratory lung volume (EELV) differed significantly ( p < 0.0001), with highest values in OLC (64% [60-70%]) and lowest in ARDSnet-low (34% [24-37%]). Costa's surrogate for mechanical power differed significantly ( p < 0.0001), with lowest values for ARDSnet-high (73 [58-76]) compared with OLC (105 [108-116]). Diffuse alveolar damage was lower in ARDSnet-high compared with ARDSnet-low (0.0007). Progression to ARDS, 24 hours after PC, was mitigated by OLC and ARDSnet-high. Both concepts restored EELV. ARDSnet-high had the lowest mechanical power surrogate and DAD. Our data suggest, that ARDSnet-high restored oxygenation and functional lung volume and reduced physiological and histological surrogates for VILI. ARDSnet-low generated unfavorable outcomes, such as loss of EELV, increased mechanical power and DAD after PC in swine. The high respiratory rate in the OLC may blunt favorable effects of lung recruitment.

Pulmonary contusion: automated deep learning-based quantitative visualization.

Rapid automated CT volumetry of pulmonary contusion may predict progression to Acute Respiratory Distress Syndrome (ARDS) and help guide early clinical management in at-risk trauma patients. This study aims to train and validate state-of-the-art deep learning models to quantify pulmonary contusion as a percentage of total lung volume (Lung Contusion Index, or auto-LCI) and assess the relationship between auto-LCI and relevant clinical outcomes. 302 adult patients (age ≥ 18) with pulmonary contusion were retrospectively identified from reports between 2016 and 2021. nnU-Net was trained on manual contusion and whole-lung segmentations. Point-of-care candidate variables for multivariate regression included oxygen saturation, heart rate, and systolic blood pressure on admission. Logistic regression was used to assess ARDS risk, and Cox proportional hazards models were used to determine differences in ICU length of stay and mechanical ventilation time. Mean Volume Similarity Index and mean Dice scores were 0.82 and 0.67. Interclass correlation coefficient and Pearson r between ground-truth and predicted volumes were 0.90 and 0.91. 38 (14%) patients developed ARDS. In bivariate analysis, auto-LCI was associated with ARDS (p < 0.001), ICU admission (p < 0.001), and need for mechanical ventilation (p < 0.001). In multivariate analyses, auto-LCI was associated with ARDS (p = 0.04), longer length of stay in the ICU (p = 0.02) and longer time on mechanical ventilation (p = 0.04). AUC of multivariate regression to predict ARDS using auto-LCI and clinical variables was 0.70 while AUC using auto-LCI alone was 0.68. Increasing auto-LCI values corresponded with increased risk of ARDS, longer ICU admissions, and longer periods of mechanical ventilation.

Tracheal bifurcation repair for blunt thoracic trauma in a patient with COVID-19

BackgroundTracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support.Case presentationThis is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications.ConclusionsECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus.

NARROWING THE GAP: PRECLINICAL TRAUMA WITH POSTINJURY SEPSIS MODEL WITH INCREASED CLINICAL RELEVANCE.

Background : Overall outcomes for trauma patients have improved over time. However, mortality for postinjury sepsis is unchanged. The use of relevant preclinical studies remains necessary to understand mechanistic changes after injury and sepsis at the cellular and molecular level. We hypothesized that a preclinical rodent model of multicompartmental injury with postinjury pneumonia and chronic stress would replicate inflammation and organ injury similar to trauma patients in the intensive care unit. Methods : Male and proestrus female Sprague-Dawley rats ( n = 16/group) were subjected to either polytrauma (PT) (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofracture), PT with daily chronic restraint stress (PT/CS), PT with postinjury day one Pseudomonas pneumonia (PT + PNA), PT/CS with pneumonia (PT/CS + PNA) or naive controls. Weight, white blood cell count, plasma toll-like receptor 4 (TLR4), urine norepinephrine (NE), hemoglobin, serum creatinine, and bilateral lung histology were evaluated. Results : PT + PNA and PT/CS + PNA groups lost more weight compared with those without sepsis (PT, PT/CS) and naive rats ( P < 0.03). Similarly, both PT + PNA and PT/CS + PNA had increased leukocytosis and plasma TLR4 compared with uninfected counterparts. Urine NE was elevated in PT + PNA and PT/CS + PNA compared with naive ( P < 0.03), with PT/CS + PNA exhibiting the highest levels. PT/CS + PNA exhibited worse acute kidney injury with elevated serum creatinine compared with PT/CS ( P = 0.008). PT/CS + PNA right and left lung injury scores were worse than PT + PNA ( P < 0.01). Conclusions : Sepsis, with postinjury pneumonia, induced significant systemic inflammation, organ dysfunction following polytrauma and chronic stress. Advanced animal models that replicate the critically ill human condition will help overcome the classic limitations of previous experimental models and enhance their translational value.

Effect of amifostine on pulmonary contusion from blunt chest trauma in rats

Purpose: To investigate the efficacy of different doses of amifostine (AMI) and dexamethasone (DXM) on bilateral pulmonary contusion in rats.&#x0D; Methods: Forty-two Sprague Dawley rats were divided into six groups of seven animals each (control, pulmonary contusion (PC), PC + AMI 400 mg/kg, PC + AMI 200 mg/kg, PC + AMI 400 mg/kg + DXM, and PC + DXM-treated groups). RelAssay commercial kit was used to determine total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI). Nitric oxide (NO), inducible nitric oxide synthase (iNOS), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) activity associated with blunt trauma induced pulmonary damage were determined by enzyme-linked immunosorbent assay (ELISA). Blood gas was determined using a blood gas analyzer, while histopathological examinations were performed on the tissues by hematoxylin and eosin (H &amp; E) staining method.&#x0D; Results: Significant improvement in biochemical parameters and histopathological findings were observed in the groups treated with dexamethasone and high-dose amifostine (400 mg/kg; p &lt; 0.05). However, low-dose amifostine (200 mg/kg) and a combination of dexamethasone with amifostine (400 g/kg) was ineffective in balancing the biochemical changes due to trauma (p &gt; 0.05).&#x0D; Conclusion: High-dose amifostine combined with dexamethasone mitigates trauma-induced damage in rat by preventing the elevation of key inflammatory markers. Further preclinical and clinical studies are required to determine the efficacy of amifostine in humans and to compare its activity with other agents.

Pulmonary contusion: clinical reasoning

According to statistics, chest injuries rank third in prevalence and are characterized by high mortality, which is 35 – 45%. This article presents a patient diagnosed and treated for bilateral pulmonary contusion with post-traumatic pneumonitis after a combined mine-explosive injury. Purpose. Of particular interest to the clinician is the understanding of lung injury from the standpoint of interpretation of diagnosis, methods of diagnosis, and differential diagnosis with pneumonia, prevention of complications, and rational treatment tactics. The terms “pneumonitis” and “pneumonia” are not synonymous. In modern terminology, it is customary to use the term pneumonitis for a pathologic process in the alveoli without an infectious process in the vast majority of cases, and infectious forms of pulmonary inflammation are referred to as pneumonia. In this clinical case (and in similar situations), it is advisable to take into account the pathogenesis of changes in lung tissue after pulmonary contusion, leading to post-traumatic pneumonitis, which often requires additional specific therapy and rehabilitation for rapid recovery of lung function. Proper tactics in prescribing anti-inflammatory and antibacterial drugs are critical, as is treatment aimed at preventing complications, including prevention of fibrous changes in the lung. Conclusion. Given the relevance of this topic, it is currently advisable to introduce monitoring of CRP and procalcitonin levels, coagulogram, and gas composition of arterial blood, if necessary, in the patient management. It is advisable to use computed tomography to clarify the nature of the changes. The problem of follow-up and rehabilitation of patients with chest injuries and pulmonary contusion is relevant.

The Relationship between Thoracic Trauma Scoring and Mortality in Blunt Thoracic Trauma Patients at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Introduction: Closed thoracic trauma is frequently associated with rib fractures and pulmonary contusions. Thoracic trauma can be life-threatening if it is not treated immediately and properly. This study aimed to determine the relationship between thoracic trauma scoring and mortality in blunt thoracic trauma patients in sub-population Indonesia, especially at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.&#x0D; Methods: This study is a cross-sectional observational study. A total of 70 research subjects participated in this study. Data analysis was carried out using SPSS in univariate and bivariate to determine the relationship between thoracic trauma scoring and mortality.&#x0D; Results: There is a significant relationship between CTS scores and mortality (p = 0.000). Patients with a CTS score ≥ 5 were significantly more at risk of dying than patients with a CTS score &lt; 5 (p = 0.000).&#x0D; Conclusion: There is a relationship between CTS score and blunt trauma patient mortality thorax at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.

Association of Chest Anteroposterior Radiography with Computed Tomography in Patients with Blunt Chest Trauma.

In cases of chest trauma, computed tomography (CT) can be used alongside chest anteroposterior (AP) radiography and physical examination during initial evaluation. Performing a CT scan may be difficult if a patient has unstable vital signs. In contrast, radiography may not always reliably diagnose nonmarked pneumothorax or extensive subcutaneous emphysema. This study aimed to determine the agreement between chest radiography and CT findings in patients with blunt chest trauma. The study also aimed to determine the occurrence of occult pneumothorax and clarify the proportion of subcutaneous emphysema and pneumothorax detected through radiography and CT, respectively. We included patients (n = 1284) with chest trauma who were admitted to the emergency room of a tertiary hospital between January 2015 and June 2022. We excluded patients aged <18 years, those with stab injury, those without radiography and CT findings, and patients who required iatrogenic intervention, such as chest tube insertion, before imaging. We recorded age, sex, trauma mechanism, and Abbreviated Injury Scale score for each patient. From radiography and CT scans, we recorded the presence of rib fracture, subcutaneous emphysema, lung contusion, pneumothorax, and pneumomediastinum. The accuracy, sensitivity, specificity, and positive and negative predictive values were calculated to assess the reliability of radiography as a predictor of CT-based diagnosis. Radiography exhibited a specificity of nearly 100% for all items. In most cases, findings that could not be confirmed by CT were not evident on radiographs. The incidence of occult pneumothorax was 87.3%. When subcutaneous emphysema was observed on radiography, CT findings indicated pneumothorax in 96.7% of cases. In situations where the patient's vital signs are unstable and performing a CT scan is not feasible, the presence of subcutaneous emphysema on radiography may indicate the need for chest decompression, even if pneumothorax is not observed.

Bilateral thoracic trauma-"double the trouble"?

Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma. The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two. In aretrospective study, data from all patients diagnosed with thoracic trauma at alevelI trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome. A total of 714patients were included in the analysis. The mean Injury Severity Score (ISS) was19. Patients with an additional thoracic spine injury had asignificantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for achest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors. Patients with bilateral chest trauma had an increased incidence of complications and ahigher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Assessment of a Perfusion and Ventilation Method for Detecting Lung and Liver Injury in a Cadaveric Model.

Surgical simulation models have been developed using post-mortem human subjects (PMHS). These models involve the pressurization and ventilation of the PMHS to create a more realistic environment for training and the practice of surgical procedures. The overall objective of this study was to determine the feasibility of a previously developed surgical simulation model to detect soft tissue injuries during a ballistic impact to the torso. One of the main limitations of using PMHS for the assessment of soft tissue injuries in the field of injury biomechanics is the lack of physiological blood flow. To overcome this limitation, the assessment of the surgical simulation model for use in injury biomechanics applications was conducted based on data collected from behind armor blunt trauma (BABT) case studies. Documented injuries in real-world cases included anterior lung contusion, posterior lung contusion, and liver contusion. These real-world injuries were compared to those seen post-impact in the PMHS using pathological and histological techniques. Discussion of limitations and future work is presented.

Man With Chest Pain After a Traffic Crash.

A 40-year-old man had been involved in a scooter crash and presented to the emergency department with chest pain. His vital signs were blood pressure, 160/84 mmHg; pulse, 109 beats/min; respiratory rate 24 breaths/min, and temperature, 37.5 °C. Physical examination revealed severe local tenderness in the mid-chest region. Plain radiography (Figure 1) and point-of-care ultrasonography of the chest (Figure 2 and Video 1) were performed, and the diagnosis was confirmed by contrast-enhanced computed tomography.Figure 2The point-of-care ultrasound at the site of pain showed a breach in the anterior cortex of the sternal body (arrowhead) and a mass with mixed echogenicity around the fracture indicating hematoma (asterisk).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Sternum fracture. Plain radiography revealed a suspicious mild depression fracture of the sternum. Point-of-care ultrasound imaging, using a high-frequency linear transducer at the site of pain, showed a discontinuous outline of the sternum. A chest computed tomography (Figure 3) image was obtained for confirmation of the diagnosis and to detect possible concomitant associate injuries, such as great vessel disruption, cardiac contusion, and pulmonary contusion. Sternum fracture is characterized by chest pain, which worsens with deep inspiration and shortness of breath. Motor vehicle crashes are the leading cause of sternum fracture, typically due to hitting the steering wheel without an airbag.1Oyetunji T.A. Jackson H.T. Obirieze A.C. et al.Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank.Am Surg. 2013; 79: 702-705Crossref PubMed Google Scholar,2Knobloch K. Wagner S. Haasper C. et al.Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims.Ann Thorac Surg. 2006; 82: 444-450Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Conventional chest radiography has variable diagnosis accuracy, and most sternal fractures may be missed by chest radiography alone.3Perez M.R. Rodriguez R.M. Baumann B.M. et al.Sternal fracture in the age of pan-scan.Injury. 2015; 46: 1324-1327Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The point-of-care ultrasound can be considered a useful technique in identifying sternum fractures.4You J.S. Chung Y.E. Kim D. et al.Role of sonography in the emergency room to diagnose sternal fractures.J Clin Ultrasound. 2010; 38: 135-137PubMed Google Scholar https://www.annemergmed.com/cms/asset/9b3c776c-e7a2-4271-9e98-27acc23ff9ab/mmc1.mp4Loading ... Download .mp4 (3.14 MB) Help with .mp4 files Video 1The point-of-care ultrasound at the site of pain showed a breach in the anterior cortex of the sternal body (arrowhead) and a mass with a mixed echogenicity around the fracture indicating hematoma (asterisk).

Endovascular reconstruction of aortic bifurcation for aortic pseudoaneurysm in a pediatric trauma patient

Endovascular treatment options for vascular injury in pediatric patients are quite limited owing to concerns regarding long-term durability and the lack of devices suitable for the pediatric anatomy. However, in rare circumstances, open surgical therapy will not be an option, and patients will require unconventional endovascular solutions for lifesaving or limb-saving therapies. In the present report, we describe an endovascular treatment of a pediatric patient for whom initial surgical management of a blunt abdominal aortic injury had failed, with subsequent development of an aortic pseudoaneurysm. A 10-year-old girl had presented after a high-speed motor vehicle accident with a seatbelt sign. Multiple abdominal injuries were identified, including blunt aortic injury, significant devitalization of the small bowel, colonic perforation with fecal contamination, multiple lumbar spine fractures, and pulmonary contusions. The patient developed bilateral lower extremity ischemia from the aortic injury and had initially undergone open repair. One month later, the patient had developed a pseudoaneurysm of the aorta near the aortic bifurcation. Because of the hostile abdomen and ensuing short gut syndrome, the pseudoaneurysm was managed using endovascular techniques. The limb of an Excluder internal iliac branch endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) was used as the endograft. The aortic bifurcation was raised and reconstructed using four Viabahn self-expanding stents (W.L. Gore & Associates). The completion angiogram showed complete resolution of the pseudoaneurysm. The follow-up computed tomography angiogram showed widely patent stent grafts with complete resolution of the pseudoaneurysm. Endovascular management of traumatic vascular injuries in pediatric patients is feasible. The likelihood of reintervention in the future is high with patient growth. However, it is a viable option in lifesaving or limb-saving situations in which open repair is high risk.

1036 Traumatic Complications of Unrecognized Somnambulance in a Pediatric Patient

Abstract Introduction Parasomnias are unusual, disruptive, and abnormal verbal or motor events that occur during sleep or between wake and sleep transitions. They can occur in non-rapid eye movement (NREM) or rapid eye movement (REM) sleep stages. NREM parasomnias are typically more prevalent in pediatric populations. One such NREM parasomnia is sleep walking or somnambulance. One study estimates somnambulance has a prevalence of 17% in ages 3-13 years¹. Somnambulance typically occurs during stage 3 sleep which is clustered in the first half of sleep when REM is less prevalent Report of case(s) A 4-year-old previously healthy male presented to clinic for a somnambulance consult. Around 6 months prior, his parents awoke around 3 AM to check on their crying infant, a sibling of our patient, and noticed the patient was missing. They noticed the back door open. Two blocks away they saw police lights and found he had been hit by a vehicle. He was admitted to the hospital for polytrauma, including bilateral pulmonary contusions with acute respiratory failure, grade 4 liver and kidney lacerations, grade 3 adrenal injury, and right parietal lobe parenchymal and subarachnoid hemorrhages. He was later discharged in stable condition with persistent but improved spasticity, impaired mobility, and cognition. His parents had not noticed any prior episodes of somnambulance. However, they did report other frequent parasomnias: somniloquy and confusional arousals. These episodes were worse following late evenings. There was a strong family history of somnambulance in the parent’s siblings. They denied any sleep disordered breathing symptoms. Parents were reassured and educated about parasomnia's self-limited nature but to keep a safe environment and avoid sleep deprivation. Conclusion The majority of parasomnia in children have benign outcomes and eventual self-resolution with age. However, rare circumstances arise where these events can be hazardous including sleep-cooking, risking fire and burns or, as in this case, unknowingly walking into traffic. A sleep study is not always needed as parasomnias are a clinical diagnosis. However, it’s important to note that if a patient has a history of parasomnias parents should be educated on the importance of keeping a safe environment to prevent possible harm. Support (if any)

The pattern and out come of lung contusion post bomb blast attack

The pattern and out come of lung contusion post bomb blast attack

Safety of Nurse-Managed Inhaled Nitric Oxide During Critical Care Interfacility Transport.

Inhaled nitric oxide (iNO) is an advanced therapy typically managed by physicians and respiratory therapists in order to increase arterial oxygenation and decrease pulmonary arterial pressure. The Johns Hopkins Lifeline Critical Care Transportation Program (Lifeline) initiated a novel nurse-managed iNO protocol in order to optimize the oxygenation of critically ill patients during interfacility transport. This study was a retrospective chart review of adverse events associated with iNO initiation or continuation by Lifeline on patients transported from March 1, 2020, to August 1, 2022. Basic demographic data and adverse events were recorded. Recorded adverse events included hypotension defined as a mean arterial pressure (MAP) < 65 mm Hg, hypoxemia defined as a decrease of ≥ 10% arterial oxygenation saturation measured by pulse oximetry, new bradycardia or tachyarrhythmia, nitrogen dioxide (NO2) levels greater than 1.0 ppm, methemoglobinemia, and cardiac arrest. Fifteen patients were diagnosed with SARS-CoV-2 infection, of which one also had pulmonary emboli, 2 had bacterial pneumonia, 1 suffered cardiogenic shock from occlusive myocardial infarction and were on VA-ECMO, and 2 had significant thoracic trauma resulting in pulmonary contusions and hemopneumothorax. iNO was continued on 10 patients and initiated on 8 patients, 2 of whom were transitioned from inhaled epoprostenol. Hypotension occurred in 3 (16.7%) patients and one (5.56%) of the hypotensive patients subsequently went on to experience new atrial fibrillation with vasopressor titration. No patients developed worsening hypoxemia, elevated NO2 levels, methemoglobinemia, or suffered cardiac arrest. All 3 patients who experienced hypotension were already on vasopressor support and the hypotension resolved with medication titration. This study shows that iNO administration can be safely managed by appropriately trained nurses.