Severe Thoracic Trauma Research Articles

Improved Discriminability of Severe Lung Injury and Atelectasis in Thoracic Trauma at Low keV Virtual Monoenergetic Images from Photon-Counting Detector CT

Objectives: To evaluate the value of virtual monoenergetic images (VMI) from photon-counting detector CT (PCD-CT) for discriminability of severe lung injury and atelectasis in polytraumatized patients. Materials & Methods: Contrast-enhanced PCD-CT examinations of 20 polytraumatized patients with severe thoracic trauma were included in this retrospective study. Spectral PCD-CT data were reconstructed using a noise-optimized virtual monoenergetic imaging (VMI) algorithm with calculated VMIs ranging from 40 to 120 keV at 10 keV increments. Injury-to-atelectasis contrast-to-noise ratio (CNR) was calculated and compared at each energy level based on CT number measurements in severely injured as well as atelectatic lung areas. Three radiologists assessed subjective discriminability, noise perception, and overall image quality. Results: CT values for atelectasis decreased as photon energy increased from 40 keV to 120 keV (mean Hounsfield units (HU): 69 at 40 keV; 342 at 120 keV), whereas CT values for severe lung injury remained near-constant from 40 keV to 120 keV (mean HU: 42 at 40 keV; 44 at 120 keV) with significant differences at each keV level (p < 0.001). The optimal injury-to-atelectasis CNR was observed at 40 keV in comparison with the remaining energy levels (p < 0.001) except for 50 keV (p > 0.05). In line with this, VMIs at 40 keV were rated best regarding subjective discriminability. VMIs at 60–70 keV, however, provided the highest subjective observer parameters regarding subjective image noise as well as image quality. Conclusions: Discriminability between severely injured and atelectatic lung areas after thoracic trauma can be substantially improved by virtual monoenergetic imaging from PCD-CT with superior contrast and visual discriminability at 40–50 keV.

Severe Thoracic Trauma Indications and Contraindications for Non-operative and Operative Treatment Strategies

Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At <4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, >6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.

Complications after conservative vs. operative treatment of severe thoracic trauma

Thoracic trauma is afrequent injury in the routine treatment of injured patients. Due to the increasing demographic changes afurther increase is to be expected, especially after low-energy trauma. Expected complications after conservative vs. operative treatment of various injury patterns of thoracic trauma. Evaluation of aselective literature search regarding possible complications after thoracic trauma and formulation of instructions for action as expert recommendations. Both conservative and operative treatment of thoracic trauma have their specific complications, which have to be known to the treating physician. Lung contusions are often underestimated in the initial radiological diagnostics but often lead to relevant problems during the further course of treatment. After conservative treatment of rib fractures persistent pain, functional limitations or even relevant deformities due to secondary dislocation, can remain. There is asignificant risk of overlooking or underestimating relevant injuries during the initial diagnostics which then leads to secondary complications. By far the most frequent risk of surgical treatment is an incorrect positioning of chest tubes. Overall, postoperative infections after chest trauma are relatively rare.

Pneumopericardium following severe thoracic trauma

BackgroundTraumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication. Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury. MethodsWe conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management. ResultsOver a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18–77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC. ConclusionsTraumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.

The critical role of anaesthesia in multifaceted care for severe thoracic trauma: A case study

Blunt trauma to the thorax can be viciously dangerous and carries high mortality which warrants aggressive resuscitation and life-saving measures failing which cardiac arrest can occur. We present a case of a polytrauma male patient in the emergency department with diaphragmatic rupture, and bilateral pelvic and clavicular fractures in hypovolemic shock which progressed to cardiac arrest. The patient was immediately resuscitated with Cardiopulmonary and cerebral resuscitation (CPCR) according to Advanced cardiac life support (ACLS) guidelines and stabilized with intravenous fluids and further optimized with blood products. He was operated on for diaphragmatic rupture and shifted to intensive care where he was paralysed and kept on mechanical ventilation for 48 hours treated for severe metabolic acidosis and hemodynamic instability following which he was weaned off successfully. During his stay, he was evaluated for pelvic and clavicular fractures and treated for ICU-related delirium and Methicillin Resistant Staphylococcus infection(MRSA). Our case suggests that diaphragmatic injuries are uncommon but deadly in cases of abdominal forceful trauma because they can result in hemothorax and the movement of intestinal contents into the thoracic cavity. Such cases must be managed with clinical knowledge employing expedient surgical care and the best critical care. This case demonstrates the indispensable and undeniable contributions by anaesthesiologists who assume multiple roles within a hospital setup.

Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study

BackgroundA significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma. MethodsThis retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV. ResultsThe final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0–18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63–5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21–1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23–6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62–5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18–2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49–63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15–2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84–17.68, p = 0.003) were independently associated with MV for more than 14 days. ConclusionsSeveral predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.

Earthquake-related isolated blunt thoracic trauma patients: A special population study in the emergency department

ObjectiveThe objective of this study is to compare patients with severe and mild blunt thoracic trauma, who survived an earthquake and presented to the emergency department (ED), in order to identify factors influencing the severity of trauma in earthquake-related thoracic injuries. MethodsThis retrospective, cross-sectional, observational comparative study included patients with isolated thoracic injuries due to the February 6th Kahramanmaraş earthquake. The patients were categorized into severe and mild groups based on chest trauma scoring (CTS), and their characteristics were compared. ResultsThe study included 53 patients, with 43 (88.1%) classified as having mild thoracic trauma and 10 (18.9%) classified as having severe thoracic trauma. There was no significant difference in the duration of entrapment between the groups (p = 0.824). The incidence of hemothorax, pneumothorax, rib fractures, and pneumomediastinum did not differ significantly between the two groups (p > 0.05). However, severe thoracic trauma was associated with a higher rate of lung contusion compared to the mild group (p = 0.045). The severe group exhibited significantly higher median scores for lung contusion, rib fractures, and total CTS compared to the mild group (p < 0.001). The mortality rate was significantly higher in the severe group (40%, n = 4) compared to the mild group (2.3%, n = 1) (p = 0.003). ConclusionThe duration of entrapment did not significantly affect the severity of thoracic injuries in earthquake-related blunt thoracic trauma. However, lung contusion was found to be a more prominent feature in these injuries compared to other clinical conditions such as hemothorax and pneumothorax. These findings highlight the distinct clinical implications of earthquake-related thoracic trauma and may have implications for management strategies in these cases.

Extracorporeal life support use in limited lung function: a narrative review.

In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation. A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria. To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support. Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

Removal of obstructive organized tracheo-bronchial clots under respiratory support using veno-venous extracorporeal membrane oxygenation in a patient with blunt thoracic trauma: a case report

BackgroundIt has been reported that veno-venous extracorporeal membrane oxygenation is useful for treating patients with acute respiratory failure following severe thoracic trauma. However, the removal of an obstructive organized tracheo-bronchial clot under respiratory support using extracorporeal membrane oxygenation in a patient with trauma has never been reported.Case presentationA teenage female was injured in a fall and experienced right open hemopneumothorax and bilateral lung contusions. Since she was in refractory shock due to bleeding into the right thoracic cavity, we performed right thoracotomy and resection of the lacerated right middle lobe. After hemorrhage control, her respiratory status could not be maintained under mechanical respiratory support. Therefore, we initiated veno-venous extracorporeal membrane oxygenation. Although her respiratory failure gradually improved, the removal of obstructing tracheo-bronchial organized blood clots using bronchoscopy was required daily. Because of the size and firm adherence of organized clots to the airway membrane, we performed a tracheostomy to remove organized clots directly through the incision under extracorporeal membrane oxygenation without any adverse events on day 9. The next day, she was successfully removed from extracorporeal membrane oxygenation.ConclusionsExtracorporeal membrane oxygenation could provide respiratory support not only for acute respiratory failure but also for removal of obstructing tracheo-bronchial organized clots in patients with severe lung injury following trauma.

Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia.

Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort. This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates. The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001). This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.

Severe non-cardiovascular thoracic trauma: diagnostic clues on computed tomography

ObjectiveAbout 60% of multiple trauma patients have thoracic trauma, and thoracic trauma results in the death of 10% of these patients. Computed tomography (CT) is the most sensitive and specific imaging modality for the diagnosis of acute disease, and it helps in the management and prognostic evaluation of patients with high-impact trauma. This paper aims to show the practical points that are key for diagnosing severe non-cardiovascular thoracic trauma by CT. ConclusionKnowing the key features of severe acute thoracic trauma on CT is crucial to avoid diagnostic errors. Radiologists play a fundamental role in the accurate early diagnosis of severe non-cardiovascular thoracic trauma, because the patient’s management and outcome will depend largely on the imaging findings.

Quality of life outcomes after surgical intervention in patients with multiple rib fractures: A prospective cohort study.

Optimized conservative treatment of rib fractures has long been practiced, but surgical fixation has not been promising until recently. We aimed to examine and analyze immediate postoperative outcomes and 6-month quality of life after injury in patients with moderately severe traumatic rib fractures. We conducted a prospective cohort study between July 2017 and June 2019 at the National Taiwan University Hospital. Seventy-two patients with moderately severe thoracic trauma were enrolled; 38 received conservative treatment and 34 underwent surgical fixation. Quality of life was measured using the 36-item Short Form Survey at; the first 3 days of hospitalization; before discharge; and at 1-, 2-, and 6-month follow-ups (visits 1-5). Baseline characteristics and clinical outcomes were recorded, and linear regression analysis was conducted using the generalized estimating equation. Among patients with moderately severe thoracic injury (chest Abbreviated Injury Scale score≥ 2), the operative group had more severe injuries and longer intensive care unit and in-hospital stays. However, they had a comparable quality of life 6 months after injury and higher physical component scores in the early postoperative period. Linear regression analysis obtained an equation with several factors positively affecting prediction of the mean physical component score, such as body mass index ≤25, age ≤36 years, fewer ribs requiring fixation, and diabetes mellitus. Mental component score did not show an upward trend, but the Work Quality Index largely determined the predicted mean value of the mental component score. Surgical rib fixations hasten recovery in patients with severe thoracic injury (chest Abbreviated Injury Scale ≥3) to achieve 6-month quality of life comparable to patients injured less severely (chest Abbreviated Injury Scale ≥2). The ability to resume previous work positively influenced the mental component score; thus, surgical intervention should also aim to help patients regain their social function.

Comparison of trauma scoring system in predicting post-surgical fixation outcomes of traumatic rib fracture

Background: Several trauma scoring systems have been widely used to determine the prognosis of trauma patients, but their use for post-surgical fixation of traumatic rib fracture patients has not yet been reported. This study aimed to compare several trauma scoring systems in predicting post-surgical fixation outcomes of traumatic rib fractures. Methods: A retrospective analytical study was conducted at a single tertiary hospital. Inclusion criteria were patients who suffered multiple rib fractures and were eligible for surgical rib fixation from January 2019 to July 2022. The outcomes of the study were the length of hospitalization (LHS) and intensive care unit stay (LICU), duration of thoracostomy tube insertion (DTT), the need for mechanical ventilation (NMV), and mortality post-surgery. The correlations of trauma scoring systems and measured outcomes were evaluated by bivariate and multivariate analysis. Cut-off values were determined utilizing a receiver operating characteristic curve. Results: The study involved 110 patients. All measured trauma scores were significantly correlated with the measured outcomes. Injury Severity Score (ISS) performed better to predict LHS (p=0.004) and DTT (p=0.007). Revised Trauma Score (RTS) was a good predictor of LICU (p≤0.001) and NMV (p=0.001; OR=0.39). Thoracic Trauma Severity Score (TTSS) was independent predictor of mortality (p=0.015; OR=2.28) and the NMV post-surgery (p=0.047; OR=1.320). Conclusion: Patients who have suffered severe thoracic trauma should be assessed using trauma scores, which may predict various in-hospital outcomes and should be used complementarily with other trauma scoring systems to minimize the incidence of mortality and morbidity.

Predicting tracheostomy in multiple injured patients with severe thoracic injury (AIS ≥ 3) with the new T3P-Score: a multivariable regression prediction analysis

Multiple trauma patients with severe chest trauma are at increased risk for tracheostomy. While the risk factors associated with the need for tracheostomy are well established in the general critical care population, they have not yet been validated in a cohort of patients suffering severe thoracic trauma. This retrospective cohort study analysed data on patients aged 18 years or older who were admitted to one of the six participating academic level I trauma centres with multiple injuries, including severe thoracic trauma (AISThorax ≥ 3) between 2010 and 2014. A multivariable binary regression was used to identify predictor variables for tracheostomy and to develop the Tracheostomy in Thoracic Trauma Prediction Score (T3P-Score). The study included 1019 adult thoracic trauma patients, of whom 165 underwent tracheostomy during their intensive care unit (ICU) stay. Prehospital endotracheal intubation (adjusted OR [AOR]: 2.494, 95% CI [1.412; 4.405]), diagnosis of pneumonia during the ICU stay (AOR: 4.374, 95% CI [2.503; 7.642]), duration of mechanical ventilation (AOR: 1.008/hours of intubation, 95% CI [1.006; 1.009]), and an AISHead ≥ 3 (AOR 1.840, 95% CI [1.039; 3.261]) were independent risk factors for tracheostomy. Patients with sepsis had a lower risk of tracheostomy than patients without sepsis (AOR 0.486, 95% CI [0.253; 0.935]). The T3P-Score had high predictive validity for tracheostomy (ROCAUC = 0.938, 95% CI [0.920, 0.956]; Nagelkerke’s R2 was 0.601). The T3P-Score’s specificity was 0.68, and the sensitivity was 0.96. The severity of thoracic trauma did not predict the need for tracheostomy. Follow-up studies should validate the T3P-Score in external data sets and study the reasons for the reluctant use of tracheostomy in patients with severe thoracic trauma and subsequent sepsis.Trial registration: The study was applied for and registered a priori with the respective ethics committees.

Traumatismo torácico grave no cardiovascular: claves diagnósticas en tomografía computarizada

ObjectiveAbout 60% of polytrauma patients present thoracic traumatic injuries, accounting for approximately 10% of trauma-related deaths. Computed tomography (CT) is the most sensitive and specific imaging modality for the diagnosis of acute injuries, and it improves management and prognostic evaluation of patients with high-impact trauma. This paper aims to show practical clues that are key for diagnosing severe non-cardiovascular thoracic trauma by CT. ConclusionKnowing the key features of severe acute thoracic trauma on CT is crucial to avoid diagnostic errors. Radiologists play a fundamental role in the accurate early diagnosis of severe non-cardiovascular thoracic trauma, because the patient's management and outcome will depend largely on the imaging findings.

Predictors of Mortality for Multiple Trauma Patients with Severe Thoracic Trauma During Intensive Care of The Early Posttraumatic Period

Predictors of Mortality for Multiple Trauma Patients with Severe Thoracic Trauma During Intensive Care of The Early Posttraumatic Period

Predictors of mortality in trauma patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation

Trauma-related Acute Respiratory Distress Syndrome (TR-ARDS) mortality ranges from 30 to 80%. Extracorporeal membrane oxygenation (ECMO) has demonstrated a survival benefit in select cases of TR-ARDS. In order to provide improved patient selection, we evaluated predictors of mortality in TR-ARDS patients receiving ECMO, hypothesizing age and severe thoracic trauma as risk factors for mortality. The Trauma Quality Improvement Program (2010–2016) was queried for patients ≥ 18-years-old with TR-ARDS receiving ECMO. Survivors were compared to those who died. A multivariable logistic regression model was used for analysis and included covariates known to increase risk of mortality in trauma patients. From 362 TR-ARDS patients on ECMO, 226 (62.4%) survived and 136 (37.6%) died. Those who died were older (median, 28 vs. 24-years-old, p = 0.036) and had a higher injury severity score (29 vs. 26, p = 0.040) than survivors. After adjusting for covariates, independent predictors of mortality included a severe head (OR=2.66, CI=1.29–5.49, p = 0.008) and thorax (OR =3.52, CI=1.96–6.33, p < 0.001) injury. Age ≥ 65-years-old was not a predictor of mortality ( p = 0.432). Age ≥ 65 years did not appear to increase the risk of mortality in patients with TR-ARDS receiving ECMO. However, those with severe head or thorax injury had more than a two-fold and three-fold increased risk of death, respectively. TR-ARDS patients differ from medical ARDS patients in terms of etiology, age and injuries. Thus, prior pre-ECMO mortality prediction models may lack predictive capability for trauma patients. Future prospective studies are needed to confirm our findings and develop guidelines for utilization of ECMO for trauma patients.

Кардіопротективні властивості торакальної паравертебральної блокади в гострому періоді закритої торакальної травми різного ступеня тяжкості

Вступ. Адекватність аналгезії при тяжкій закритій торакальній травмі (ЗТТ) забезпечується регіонарними методами знеболювання, одним із яких є торакальна паравертебральна блокада (ТПБ), яка вже довела свою ефективність. Проте не наведені дослідження впливу ТПБ на перебіг саме ушкодження серця після ЗТТ. Мета. Виявлення впливу ТПБ, проведеної в гострому періоді ЗТТ, на перебіг первинних і вторинних травматичних ушкоджень серця. Матеріали та методи. Контрольоване проспективне нерандомізоване дослідження засновано на аналізі лікування 82 постраждалих із ЗТТ: 70 (85,4 %) чоловіків, 12 (14,6 %) жінок, віком 53 (45, 65) роки. Групи сформовані за тяжкістю ЗТТ, де у підгрупах («a», «b») порівнювалася ефективність системної аналгезії (нестероїдні протизапальні засоби (НПЗЗ) та опіоїд) і ТПБ, проведеної у гострому періоді й надалі упродовж 4–5 діб. 1-ша групa — Injury Severity Score (ISS) — 16,0 ± 4,4 бала, APACHE II — 11,7 ± 3,6; 2-га група — ISS — 17,1 ± 3,9 бала, APACHE II — 13,8 ± 4,1; 3-тя група — ISS — 18,5 ± 4,9 бала, APACHE II — 14,5 ± 2,3. Результати. ЗТТ (ISS — 18 (14, 20) балів) із контузійним ушкодженням легенів І і ІІ ступеня у 62 (76 %) постраждалих (у 22 % виявлено на 1-шу добу, у 79 % — на 2-гу — 3-тю добу) ускладнювалася струсом чи забоєм серця до 70 % спостережень, післятравматичною міокардіо­дистрофією у ранньому та відновлювальному періодах — майже в усіх постраждалих. На електрокардіограмі (ЕКГ) — субендокардіальні та субепікардіальні зміни, пробіжки тахікардії, екстрасистоли, неспецифічні зміни кінцевої частки шлуночкового комплексу, ознаки інфаркту міокарда травматичного походження, а також і ІІ типу через крововтрату (у 2 пацієнтів). Не виявлено різниці ЕКГ-ознак між гемодинамічно стабільними і нестабільними пацієнтами. Застосування НПЗЗ та опіоїду (n = 43, підгрупи «а») достатньою мірою не усувало біль і гіпоксемію, зберігався периферичний вазоспазм (загальний периферичний судинний опір (ЗПСО) — 1987 ± 159 дин/с · см2), тахікардія (86 ± 13 уд · хв–1), зменшення роботи серця (серцевий індекс (СІ) — 2,71 ± 0,27 л/м2 · хв). Застосування ТПБ (n = 39, підгрупи «b») одразу знижувало біль на 68 ± 7 %, забезпечувало ліпше SрО2 95,6 ± 1,7 % проти 94,1 ± 1,5 % та РаО2/FіО2 340 ± 25 проти 312 ± 50 у підгрупах «а», що поєднувалось зі зменшенням тахікардії (80 ± 7 уд · хв–1) та периферичного судинного опору (ЗПСО — 1692 ± 157 дин/с · см2; p = 0,01) при одночасному сприятливому збільшенні продуктивності серцевої діяльності (СІ — 3,1 ± 0,17 л/м2 · хв). На 5-ту добу на фоні ТПБ РаО2/FiО2 був вищий, ніж у підгрупах «а» — 380 ± 28 % проти 362 ± 27 %; SрО2 — 96,8 ± 0,7 % проти 95,1 ± 1,1 % (p = 0,02). Висновки. ТПБ, проведена одразу в гострому періоді ЗТТ через усунення болю і гіпоксемії, має кардіопротекторну дію, що виявляється в антиаритмічному та протиішемічному ефектах, запобігаючи ускладненому перебігу струсу чи забою серця, зменшуючи прояви первинної і вторинної посттравматичної міокардіодистрофії.

Experience of Respiratory Tract Nursing for Patients with Severe Thoracic Trauma in ICU

Experience of Respiratory Tract Nursing for Patients with Severe Thoracic Trauma in ICU

Predictive Factors of Ventilatory Support in Chest Trauma.

This study aims to define possible predictors of the need of invasive and non-invasive ventilatory support, in addition to predictors of mortality in patients with severe thoracic trauma. Data from 832 patients admitted to our trauma center were collected from 2010 to 2017 and retrospectively analyzed. Demographic data, type of respiratory assistance, chest injuries, trauma scores and outcome were considered. Univariate analysis was performed, and binary logistic regression was applied to significant data. The injury severity score (ISS) and the revised trauma score (RTS) were both found to be predictive factors for invasive ventilation. Multivariate analysis of the anatomical injuries revealed that the association of high-severity thoracic injuries with trauma in other districts is an indicator of the need for orotracheal intubation. From the analysis of physiological parameters, values of systolic blood pressure, lactate, and Glasgow coma scale (GCS) score indicate the need for invasive ventilatory support. Predictive factors for non-invasive ventilation include: RTS, ISS, number of rib fractures and presence of hemothorax. Risk factors for death were: age over 65, the presence of bilateral rib fractures, pulmonary contusion, hemothorax and associated head trauma. In conclusion, the need for invasive ventilatory support in thoracic trauma is associated to the patient’s systemic severity. Non-invasive ventilation is a supportive treatment indicated in physiologically stable patients regardless of the severity of thoracic injury.