European Guidelines for AP/PA chest X-rays: routinely satisfiable in a paediatric radiology division?

PubMed

Tschauner, Sebastian; Marterer, Robert; Gübitz, Michael; Kalmar, Peter I; Talakic, Emina; Weissensteiner, Sabine; Sorantin, Erich

2016-02-01

Accurate collimation helps to reduce unnecessary irradiation and improves radiographic image quality, which is especially important in the radiosensitive paediatric population. For AP/PA chest radiographs in children, a minimal field size (MinFS) from "just above the lung apices" to "T12/L1" with age-dependent tolerance is suggested by the 1996 European Commission (EC) guidelines, which were examined qualitatively and quantitatively at a paediatric radiology division. Five hundred ninety-eight unprocessed chest X-rays (45% boys, 55% girls; mean age 3.9 years, range 0-18 years) were analysed with a self-developed tool. Qualitative standards were assessed based on the EC guidelines, as well as the overexposed field size and needlessly irradiated tissue compared to the MinFS. While qualitative guideline recommendations were satisfied, mean overexposure of +45.1 ± 18.9% (range +10.2% to +107.9%) and tissue overexposure of +33.3 ± 13.3% were found. Only 4% (26/598) of the examined X-rays completely fulfilled the EC guidelines. This study presents a new chest radiography quality control tool which allows assessment of field sizes, distances, overexposures and quality parameters based on the EC guidelines. Utilising this tool, we detected inadequate field sizes, inspiration depths, and patient positioning. Furthermore, some debatable EC guideline aspects were revealed. • European Guidelines on X-ray quality recommend exposed field sizes for common examinations. • The major failing in paediatric radiographic imaging techniques is inappropriate field size. • Optimal handling of radiographic units can reduce radiation exposure to paediatric patients. • Constant quality control helps ensure optimal chest radiographic image acquisition in children.

Quality of cardio-pulmonary resuscitation (CPR) during paediatric resuscitation training: time to stop the blind leading the blind.

PubMed

Arshid, Muhammad; Lo, Tsz-Yan Milly; Reynolds, Fiona

2009-05-01

Recent evidence suggested that the quality of cardio-pulmonary resuscitation (CPR) during adult advanced life support training was suboptimal. This study aimed to assess the CPR quality of a paediatric resuscitation training programme, and to determine whether it was sufficiently addressed by the trainee team leaders during training. CPR quality of 20 consecutive resuscitation scenario training sessions was audited prospectively using a pre-designed proforma. A consultant intensivist and a senior nurse who were also Advanced Paediatric Life Support (APLS) instructors assessed the CPR quality which included ventilation frequency, chest compression rate and depth, and any unnecessary interruption in chest compressions. Team leaders' response to CPR quality and elective change of compression rescuer during training were also recorded. Airway patency was not assessed in 13 sessions while ventilation rate was too fast in 18 sessions. Target compression rate was not achieved in only 1 session. The median chest compression rate was 115 beats/min. Chest compressions were too shallow in 10 sessions and were interrupted unnecessarily in 13 sessions. More than 50% of training sessions did not have elective change of the compression rescuer. 19 team leaders failed to address CPR quality during training despite all team leaders being certified APLS providers. The quality of CPR performance was suboptimal during paediatric resuscitation training and team leaders-in-training had little awareness of this inadequacy. Detailed CPR quality assessment and feedback should be integrated into paediatric resuscitation training to ensure optimal performance in real life resuscitations.

Blunt chest trauma.

PubMed

Stewart, Daphne J

2014-01-01

Blunt chest trauma is associated with a wide range of injuries, many of which are life threatening. This article is a case study demonstrating a variety of traumatic chest injuries, including pathophysiology, diagnosis, and treatment. Literature on the diagnosis and treatment was reviewed, including both theoretical and research literature, from a variety of disciplines. The role of the advance practice nurse in trauma is also discussed as it relates to assessment, diagnosis, and treatment of patients with traumatic chest injuries.

Emergency management of blunt chest trauma in children: an evidence-based approach.

PubMed

Pauzé, Denis R; Pauzé, Daniel K

2013-11-01

Pediatric trauma is commonly encountered in the emergency department, and trauma to the head, chest, and abdomen may be a source of significant morbidity and mortality. As children have unique thoracic anatomical and physiological properties, they may present with diagnostic challenges that the emergency clinician must be aware of. This review examines the effects of blunt trauma to the pediatric chest, as well as its relevant etiologies and associated mortality. Diagnostic and treatment options for commonly encountered injuries such as pulmonary contusions, rib fractures, and pneumothoraces are examined. Additionally, this review discusses rarely encountered--yet highly lethal--chest wall injuries such as blunt cardiac injuries, commotio cordis, nonaccidental trauma, and aortic injuries.

Characterization of blunt chest trauma in a long-term porcine model of severe multiple trauma

PubMed Central

Horst, K.; Simon, T. P.; Pfeifer, R.; Teuben, M.; Almahmoud, K.; Zhi, Q.; Santos, S. Aguiar; Wembers, C. Castelar; Leonhardt, S.; Heussen, N.; Störmann, P.; Auner, B.; Relja, B.; Marzi, I.; Haug, A. T.; van Griensven, M.; Kalbitz, M.; Huber-Lang, M.; Tolba, R.; Reiss, L. K.; Uhlig, S.; Marx, G.; Pape, H. C.; Hildebrand, F.

2016-01-01

Chest trauma has a significant relevance on outcome after severe trauma. Clinically, impaired lung function typically occurs within 72 hours after trauma. However, the underlying pathophysiological mechanisms are still not fully elucidated. Therefore, we aimed to establish an experimental long-term model to investigate physiological, morphologic and inflammatory changes, after severe trauma. Male pigs (sus scrofa) sustained severe trauma (including unilateral chest trauma, femur fracture, liver laceration and hemorrhagic shock). Additionally, non-injured animals served as sham controls. Chest trauma resulted in severe lung damage on both CT and histological analyses. Furthermore, severe inflammation with a systemic increase of IL-6 (p = 0.0305) and a local increase of IL-8 in BAL (p = 0.0009) was observed. The pO2/FiO2 ratio in trauma animals decreased over the observation period (p < 0.0001) but not in the sham group (p = 0.2967). Electrical Impedance Tomography (EIT) revealed differences between the traumatized and healthy lung (p < 0.0001). In conclusion, a clinically relevant, long-term model of blunt chest trauma with concomitant injuries has been developed. This reproducible model allows to examine local and systemic consequences of trauma and is valid for investigation of potential diagnostic or therapeutic options. In this context, EIT might represent a radiation-free method for bedside diagnostics. PMID:28000769

Organ dose and risk assessment in paediatric radiography using the PCXMC 2.0

NASA Astrophysics Data System (ADS)

Ladia, A.; Messaris, G.; Delis, H.; Panayiotakis, G.

2015-09-01

Abdominal and chest radiographs are the most common examinations in paediatric radiology. X-ray examination of children attracts particular interest, mainly due to the increased risk for the expression of delayed radiogenic cancers as they have many years of expected life remaining. This study aims to calculate the organ dose and estimate the radiation Risk of Exposure Induced cancer Death (REID) to paediatric patients, using the PCXMC 2.0 Monte Carlo code.Patient data and exposure parameters were recorded during examinations of 240 patients, separated in four age groups undergoing chest or abdomen examinations.The organs received the highest dose in all patient groups were liver, lungs, stomach, thyroid, pancreas, breast, spleen in chest radiographs and liver, lungs, colon, stomach and ovaries, uterus (for girls) and prostate (for boys) in abdomen radiographs. The effective dosefor the chest was 0.49×10-2- 1.07×10-2 mSv, while for the abdomen 1.85×10-2- 3.02×10-2 mSv. The mean REID value was 1.254×10-5 for the abdomen and 0.645×10-5 for the chest.

Primary Chest Wall Abscess Mimicking a Breast Tumor That Occurred after Blunt Chest Trauma: A Case Report

PubMed Central

Masuda, Norikazu; Yasojima, Hiroyuki; Mizutani, Makiko; Nakamori, Shoji; Kanazawa, Toru; Kuriyama, Keiko; Mano, Masayuki; Sekimoto, Mitsugu

2014-01-01

Primary chest wall abscess occurring after blunt chest trauma is rare. We present the case of a 50-year-old woman who presented with a swelling in her left breast. The patient had experienced blunt chest trauma 2 months back. Needle aspiration revealed pus formation in the patient's chest. Computed tomography revealed a mass in the lower region of the left mammary gland, with thickening of the parietal pleura and skin and fracture of the fifth rib under the abscess. Following antibiotic administration and irrigation of the affected region, surgical debridement was performed. During surgery, we found that the pectoralis major muscle at the level of the fifth rib was markedly damaged, although the necrotic tissue did not contact the mammary gland. We diagnosed the lesion as a chest wall abscess that occurred in response to blunt chest trauma. Her postoperative course was uneventful. There has been no recurrence for six months after surgery. PMID:24660001

Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience.

PubMed

Veysi, Veysi T; Nikolaou, Vassilios S; Paliobeis, Christos; Efstathopoulos, Nicolas; Giannoudis, Peter V

2009-10-01

A review of prospectively collected data in our trauma unit for the years 1998-2003 was undertaken. Adult patients who suffered multiple trauma with an Injury Severity Score (ISS) of >/=16, admitted to hospital for more than 72 hours and with sustained blunt chest injuries were included in the study. Demographic details including pre-hospital care, trauma history, admission vital signs, blood transfusions, details of injuries and their abbreviated injury scores (AIS), operations, length of intensive care unit and hospital stays, Injury Severity Score (ISS) and mortality were analysed. Fulfilling the inclusion criteria with at least one chest injury were 1,164 patients. The overall mortality reached 18.7%. As expected, patients in the higher AIS groups had both a higher overall ISS and mortality rate with one significant exception; patients with minor chest injuries (AIS(chest) = 1) were associated with mortality comparable to injuries involving an AIS(chest) = 3. Additionally, the vast majority of polytraumatised patients with an AIS(chest) = 1 died in ICU sooner than patients of groups 2-5.

Limiting chest computed tomography in the evaluation of pediatric thoracic trauma.

PubMed

Golden, Jamie; Isani, Mubina; Bowling, Jordan; Zagory, Jessica; Goodhue, Catherine J; Burke, Rita V; Upperman, Jeffrey S; Gayer, Christopher P

2016-08-01

Computed tomography (CT) of the chest (chest CT) is overused in blunt pediatric thoracic trauma. Chest CT adds to the diagnosis of thoracic injury but rarely changes patient management. We sought to identify a subset of blunt pediatric trauma patients who would benefit from a screening chest CT based on their admission chest x-ray (CXR) findings. We hypothesize that limiting chest CT to patients with an abnormal mediastinal silhouette identifies intrathoracic vascular injuries not otherwise seen on CXR. All blunt trauma activations that underwent an admission CXR at our Level 1 pediatric trauma center from 2005 to 2013 were retrospectively reviewed. Patients who had a chest CT were evaluated for added diagnoses and change in management after CT. An admission CXR was performed in 1,035 patients. One hundred thirty-nine patients had a CT, and the diagnosis of intra-thoracic injury was added in 42% of patients. Chest CT significantly increased the diagnosis of contusion or atelectasis (30.3% vs 60.4%; p < 0.05), pneumothorax (7.2% vs 18.7%; p < 0.05), and other fractures (4.3% vs 10.8%; p < 0.05) on CXR compared to chest CT. Chest CT changed the management of only 4 patients (2.9%). Two patients underwent further radiologic evaluation that was negative for injury, one had a chest tube placed for an occult pneumothorax before exploratory laparotomy, and one patient had a thoracotomy for repair of aortic injury. Chest CT for select patients with an abnormal mediastinal silhouette on CXR would have decreased CT scans by 80% yet still identified patients with an intrathoracic vascular injury. The use of chest CT should be limited to the identification of intrathoracic vascular injuries in the setting of an abnormal mediastinal silhouette on CXR. Therapeutic study, level IV; diagnostic study, level III.

Chest Wall Trauma.

PubMed

Majercik, Sarah; Pieracci, Fredric M

2017-05-01

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management. Copyright © 2017 Elsevier Inc. All rights reserved.

High plasma levels of high mobility group box 1 is associated with the risk of sepsis in severe blunt chest trauma patients: a prospective cohort study.

PubMed

Wang, Xiao-Wen; Karki, Avash; Zhao, Xing-Ji; Xiang, Xiao-Yong; Lu, Zhi-Qian

2014-08-02

High mobility group box 1 (HMGB1) is a late mediator of systemic inflammation. Extracellular HMGB1 play a central pathogenic role in critical illness. The purpose of the study was to investigate the association between plasma HMGB1 concentrations and the risk of poor outcomes in patients with severe blunt chest trauma. The plasma concentrations of HMGB1 in patients with severe blunt chest trauma (AIS ≥ 3) were measured by a quantitative enzyme-linked immunosorbent assay at four time points during seven days after admission, and the dynamic release patterns were monitored. The biomarker levels were compared between patients with sepsis and non-sepsis, and between patients with multiple organ dysfunction syndrome (MODS) and non-MODS. The related factors of prognosis were analyzed by using multivariate logistic regression analysis. The short-form 36 was used to evaluate the quality of life of patients at 12 months after injury. Plasma HMGB1 levels were significantly higher both in sepsis and MODS group on post-trauma day 3, 5, and 7 compared with the non-sepsis and non-MODS groups, respectively. Multivariate analysis showed that HMGB1 levels and ISS were independent risk factors for sepsis and MODS in patients with severe blunt chest trauma. Plasma HMGB1 levels were significantly elevated in patients with severe blunt chest trauma. HMGB1 levels were associated with the risk of poor outcome in patients with severe blunt chest trauma. Daily HMGB1 levels measurements is a potential useful tool in the early identification of post-trauma complications. Further studies are needed to determine whether HMGB1 intervention could prevent the development of sepsis and MODS in patients with severe blunt chest trauma.

[Chest trauma].

PubMed

Freixinet Gilart, Jorge; Ramírez Gil, María Elena; Gallardo Valera, Gregorio; Moreno Casado, Paula

2011-01-01

Chest trauma is a frequent problem arising from lesions caused by domestic and occupational activities and especially road traffic accidents. These injuries can be analyzed from distinct points of view, ranging from consideration of the most severe injuries, especially in the context of multiple trauma, to the specific characteristics of blunt and open trauma. In the present article, these injuries are discussed according to the involvement of the various thoracic structures. Rib fractures are the most frequent chest injuries and their diagnosis and treatment is straightforward, although these injuries can be severe if more than three ribs are affected and when there is major associated morbidity. Lung contusion is the most common visceral lesion. These injuries are usually found in severe chest trauma and are often associated with other thoracic and intrathoracic lesions. Treatment is based on general support measures. Pleural complications, such as hemothorax and pneumothorax, are also frequent. Their diagnosis is also straightforward and treatment is based on pleural drainage. This article also analyzes other complex situations, notably airway trauma, which is usually very severe in blunt chest trauma and less severe and even suitable for conservative treatment in iatrogenic injury due to tracheal intubation. Rupture of the diaphragm usually causes a diaphragmatic hernia. Treatment is always surgical. Myocardial contusions should be suspected in anterior chest trauma and in sternal fractures. Treatment is conservative. Other chest injuries, such as those of the great thoracic and esophageal vessels, are less frequent but are especially severe. Copyright © 2011 Sociedad Española de Neumología y Cirugía Torácica. Published by Elsevier Espana. All rights reserved.

Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew - case identification rates and effect on the Sydney paediatric trauma system.

PubMed

Garner, Alan A; Lee, Anna; Weatherall, Andrew

2012-12-18

Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC. Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available. Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01). Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.

Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital

PubMed Central

Hefny, Ashraf F; Kunhivalappil, Fathima T; Matev, Nikolay; Avila, Norman A; Bashir, Masoud O; Abu-Zidan, Fikri M

2018-01-01

INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL. PMID:28741012

Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital.

PubMed

Hefny, Ashraf F; Kunhivalappil, Fathima T; Matev, Nikolay; Avila, Norman A; Bashir, Masoud O; Abu-Zidan, Fikri M

2018-03-01

Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL. Copyright: © Singapore Medical Association.

Occult pneumomediastinum in blunt chest trauma: clinical significance.

PubMed

Rezende-Neto, J B; Hoffmann, J; Al Mahroos, M; Tien, H; Hsee, L C; Spencer Netto, F; Speers, V; Rizoli, S B

2010-01-01

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or "overt pneumomediastinum", raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or "occult pneumomediastinum". Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population. A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated. Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p<0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p<0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam. Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.

Tube thorocostomy: management and outcome in patients with penetrating chest trauma.

PubMed

Muslim, Muhammad; Bilal, Amer; Salim, Muhammad; Khan, Muhammad Abid; Baseer, Abdul; Ahmed, Manzoor

2008-01-01

Penetrating chest trauma is common in this part of the world due to present situation in tribal areas. The first line of management after resuscitation in these patients is tube thoracostomy combined with analgesia and incentive spirometry. After tube thoracostomy following surgery or trauma there are two schools of thought one favours application of continuous low pressure suction to the chest tubes beyond the water seal while other are against it. We studied the application of continuous low pressure suction in patients with penetrating chest trauma. This Randomized clinical controlled trial was conducted in the department of thoracic surgery Post Graduate Medical Institute Lady Reading Hospital Peshawar from July 2007 to March 2008. The objectives of study were to evaluate the effectiveness of continuous low pressure suction in patients with penetrating chest trauma for evacuation of blood, expansion of lung and prevention of clotted Haemothorax. One hundred patients who underwent tube thoracostomy after penetrating chest trauma from fire arm injury or stab wounds were included in the study. Patients with multiple trauma, blunt chest trauma and those intubated for any pulmonary or pleural disease were excluded from the study. After resuscitation, detailed examination and necessary investigations patients were randomized to two groups. Group I included patients who had continuous low pressure suction applied to their chest drains. Group II included those patients whose chest drains were placed on water seal only. Lung expansion development of pneumothorax or clotted Haemothorax, time to removal of chest drain and hospital stay was noted in each group. There were fifty patients in each group. The two groups were not significantly different from each other regarding age, sex, pre-intubation haemoglobin and pre intubation nutritional status. Full lung expansion was achieved in forty six (92%) patients in group I and thirty seven (74%) in group II. Partial lung expansion or pneumothorax was present in three (60%) in group I and 10 (20%) in group II. One patient in group I and three (6%) patients in group II had no response. The mean time to removal of chest drains were 8.2 +/- 3.14 days in group I and 12.6 +/- 4.20 days in group II. The length of hospital stay was 7.2 +/- 2.07 days and 12.4 +/- 3.63 days in group I and II respectively. Clotted Haemothorax requiring surgery developed in three (6%) patients in group I and 8 (16%) patients in group II. Placing chest tubes on continuous low pressure suction after penetrating chest trauma helps evacuation of blood, expansion of lung and prevents the development of clotted Haemothorax. It also reduces the time to removal of chest drains, the hospital stay and the chances of surgery for clotted Haemothorax or Empyema.

Epidemiology and pattern of paediatric and adolescent trauma deaths in a level 1 trauma centre in Benin city, Nigeria.

PubMed

Osifo, Osarumwense David; Iribhogbe, Pius Ehiawaguan; Ugiagbe, Ezekiel Enoghama

2012-11-01

Trauma is a common cause of death amongst children/adolescents, and data on its epidemiology and pattern are crucial for policy formulation. The aim of this study was to determine the epidemiology and pattern of paediatric/adolescent trauma death in a Nigerian referral trauma centre. The clinical and autopsy data of all paediatric/adolescent trauma death at the University of Benin Teaching Hospital between 1999 and 2010 were analysed in a retrospective study. Of 905 trauma-related deaths, 78 (9%) involved children/adolescents who comprised 49 males and 29 females, with a male/female ratio 1.7:1 and a mean age of 9.2 ± 5 years (range <1-18 years). The Injury-Arrival time varied from 1h to 4 days (mean 18 h). Thirteen (17%) cases were dead on arrival (DOA), and majority of the deaths occurred within the first week on admission. Road traffic accident (RTA), accounting for 61 (78%) cases, was the leading cause of trauma death. Other causes included burns, eight (10%); gunshot injury, five (6%); and stab and sport injuries, two (3%) cases each. Head injury which occurred in 44 (56%) cases was the commonest cause of death, followed by haemorrhagic shock in 25 (32%), hypovolaemic shock in five (6%), septic shock in three (4%) and spinal cord injury in one (1%). Head injury following RTA was the major cause of paediatric/adolescent trauma deaths. Increased road safety campaign, appropriate injury control policies, legislations, enforcement, development of high-quality trauma system, and emergency medical services are advocated. Copyright © 2011 Elsevier Ltd. All rights reserved.

[Utility of digital thoracotomy in chest trauma].

PubMed

Vélez, Sebastián E; Sarquis, Guillermo

2006-01-01

toracostomy in thoracic trauma is a good opportunity for the digital exploration of pleural cavity. To evaluate the utility of digital exploration during chest tube insertion in thoracic trauma. Hospital de Urgencias. Córdoba. patients with blunt and penetrating chest trauma by stab wound, who need chest tube insertion and treated by only one surgeon, were evaluated from July 10 to December 31st 2000. Previously to the thoracostomy with 24 french tube in 5th intercostal space, at the affected side, a digital exploration of pleural cavity was done, attempting to find intrathoracic injuries. in a six months period, 36 thoracostomy tubes were placed, due thoracic trauma (11 blunt trauma and 25 penetrating, by stab wound). Three patients had positive findings in the digital exploration, which forced to do another diagnostic or therapeutic procedures. digital thoracotomy is not considered a formal procedure, but as a part of a technique, in which, the previous exploration with the finger before chest tube insertion, allows to reach a diagnosis of the pleural space situation, to confirm suspicions, to modify a conduct, and to avoid greater morbidity to patients.

Late clotted haemothorax after blunt chest trauma.

PubMed Central

Sinha, P; Sarkar, P

1998-01-01

A clotted haemothorax can develop any time after blunt chest trauma. Two cases are described in which late clotted haemothoraces developed which were treated by limited thoracotomy and evacuation of clots. Late clotted haemothorax may occur even in the absence of any abnormal initial clinical findings. Early detection and treatment is important to avoid the complications of fibrothorax and empyema with permanent pulmonary dysfunction. After blunt chest trauma patients should be advised to return to the accident and emergency department for assessment on development of any new chest symptom. Under these circumstances a chest x ray is mandatory to exclude a haemothorax. Images Figure 1 PMID:9639184

Multidetector Computer Tomography: Evaluation of Blunt Chest Trauma in Adults

PubMed Central

Matos, António P.; Mascarenhas, Vasco; Herédia, Vasco

2014-01-01

Imaging plays an essential part of chest trauma care. By definition, the employed imaging technique in the emergency setting should reach the correct diagnosis as fast as possible. In severe chest blunt trauma, multidetector computer tomography (MDCT) has become part of the initial workup, mainly due to its high sensitivity and diagnostic accuracy of the technique for the detection and characterization of thoracic injuries and also due to its wide availability in tertiary care centers. The aim of this paper is to review and illustrate a spectrum of characteristic MDCT findings of blunt traumatic injuries of the chest including the lungs, mediastinum, pleural space, and chest wall. PMID:25295188

Multidetector computer tomography: evaluation of blunt chest trauma in adults.

PubMed

Palas, João; Matos, António P; Mascarenhas, Vasco; Herédia, Vasco; Ramalho, Miguel

2014-01-01

Imaging plays an essential part of chest trauma care. By definition, the employed imaging technique in the emergency setting should reach the correct diagnosis as fast as possible. In severe chest blunt trauma, multidetector computer tomography (MDCT) has become part of the initial workup, mainly due to its high sensitivity and diagnostic accuracy of the technique for the detection and characterization of thoracic injuries and also due to its wide availability in tertiary care centers. The aim of this paper is to review and illustrate a spectrum of characteristic MDCT findings of blunt traumatic injuries of the chest including the lungs, mediastinum, pleural space, and chest wall.

Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases.

PubMed

Al-Koudmani, Ibrahim; Darwish, Bassam; Al-Kateb, Kamal; Taifour, Yahia

2012-04-19

Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria. We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality. The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%). New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis.

A dose comparison survey in CT departments of dedicated paediatric hospitals in Australia and Saudi Arabia

PubMed Central

Mohiy, Hussain Al; Sim, Jenny; Seeram, Euclid; Annabell, Nathan; Geso, Moshi; Mandarano, Giovanni; Davidson, Rob

2012-01-01

AIM: To measure and compare computed tomography (CT) radiation doses delivered to patients in public paediatric hospitals in Australia and Saudi Arabia. METHODS: Doses were measured for routine CT scans of the head, chest and abdomen/pelvis for children aged 3-6 years in all dedicated public paediatric hospitals in Australia and Saudi Arabia using a CT phantom measurement cylinder. RESULTS: CT doses, using the departments’ protocols for 3-6 year old, varied considerably between hospitals. Measured head doses varied from 137.6 to 528.0 mGy·cm, chest doses from 21.9 to 92.5 mGy·cm, and abdomen/pelvis doses from 24.9 to 118.0 mGy·cm. Mean head and abdomen/pelvis doses delivered in Saudi Arabian paediatric CT departments were significantly higher than those in their Australian equivalents. CONCLUSION: CT dose varies substantially across Australian and Saudi Arabian paediatric hospitals. Therefore, diagnostic reference levels should be established for major anatomical regions to standardise dose. PMID:23150767

[Chest trauma: who, how and what?].

PubMed

Molnár, F Tamás

2012-10-01

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Alveolar macrophage phagocytosis is enhanced after blunt chest trauma and alters the posttraumatic mediator release.

PubMed

Seitz, Daniel H; Palmer, Annette; Niesler, Ulrike; Fröba, Janine S; Heidemann, Vera; Rittlinger, Anne; Braumüller, Sonja T; Zhou, Shaoxia; Gebhard, Florian; Knöferl, Markus W

2011-12-01

Blunt chest trauma is known to induce a pulmonary invasion of short-lived polymorphonuclear neutrophils and apoptosis of alveolar epithelial type 2 (AT2) cells. Apoptotic cells are removed by alveolar macrophages (AMΦ). We hypothesized that chest trauma alters the phagocytic response of AMΦ as well as the mediator release of AMΦ during phagocytosis. To study this, male Sprague-Dawley rats were subjected to blunt chest trauma. Phagocytosis assays were performed in AMΦ isolated 2 or 24 h after trauma with apoptotic cells or opsonized beads. Phagocytosis of apoptotic AT2 cells by unstimulated AMΦ was significantly increased 2 h after trauma. At 24 h, AMΦ from traumatized animals, stimulated with phorbol-12-myristate-13-acetate, ingested significantly more apoptotic polymorphonuclear neutrophils than AMΦ from sham animals. Alveolar macrophages after trauma released significantly higher levels of tumor necrosis factor α, macrophage inflammatory protein 1α, and cytokine-induced neutrophil chemoattractant 1 when they incorporated latex beads, but significantly lower levels of interleukin 1β and macrophage inflammatory protein 1α when they ingested apoptotic cells. In vivo, phagocytosis of intratracheally instilled latex beads was decreased in traumatized rats. The bronchoalveolar lavage concentrations of the phagocytosis-supporting surfactant proteins A and D after blunt chest trauma were slightly decreased, whereas surfactant protein D mRNA expression in AT2 cells was significantly increased after 2 h. These findings indicate that chest trauma augments the phagocytosis of apoptotic cells by AMΦ. Phagocytosis of opsonized beads enhances and ingestion of apoptotic cells downregulates the immunologic response following lung contusion. Our data emphasize the important role of phagocytosis during posttraumatic inflammation after lung contusion.

Cardiac and great vessel injuries after chest trauma: our 10-year experience.

PubMed

Onan, Burak; Demirhan, Recep; Öz, Kürşad; Onan, Ismihan Selen

2011-09-01

Cardiovascular injuries after trauma present with high mortality. The aim of the study was to present our experience in cardiac and great vessel injuries after chest trauma. During the 10-year period, 104 patients with cardiac (n=94) and great vessel (n=10) injuries presented to our hospital. The demographic data, mechanism of injury, location of injury, other associated injuries, timing of surgical intervention, surgical approach, and clinical outcome were reviewed. Eighty-eight (84.6%) males presented after chest trauma. The mean age of the patients was 32.5±8.2 years (range: 12-76). Penetrating injuries (62.5%) were the most common cause of trauma. Computed tomography was performed in most cases and echocardiography was used in some stable cases. Cardiac injuries mostly included the right ventricle (58.5%). Great vessel injuries involved the subclavian vein in 6, innominate vein in 1, vena cava in 1, and descending aorta in 2 patients. Early operations after admission to the emergency were performed in 75.9% of the patients. Thoracotomy was performed in 89.5% of the patients. Operative mortality was significantly high in penetrating injuries (p=0.01). Clinicians should suspect cardiac and great vessel trauma in every patient presenting to the emergency unit after chest trauma. Computed tomography and echocardiography are beneficial in the management of chest trauma. Operative timing depends on hemodynamic status, and a multidisciplinary team approach improves the patient's prognosis.

Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system

PubMed Central

2012-01-01

Background Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC. Methods Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available. Results Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01). Conclusions Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival. PMID:23244708

Early detection of myocardial infarction following blunt chest trauma by computed tomography: a case report.

PubMed

Lee, Thung-Lip; Hsuan, Chin-Feng; Shih, Chen-Hsiang; Liang, Huai-Wen; Tsai, Hsing-Shan; Tseng, Wei-Kung; Hsu, Kwan-Lih

2017-02-10

Blunt cardiac trauma encompasses a wide range of clinical entities, including myocardial contusion, cardiac rupture, valve avulsion, pericardial injuries, arrhythmia, and even myocardial infarction. Acute myocardial infarction due to coronary artery dissection after blunt chest trauma is rare and may be life threatening. Differential diagnosis of acute myocardial infarction from cardiac contusion at this setting is not easy. Here we demonstrated a case of blunt chest trauma, with computed tomography detected myocardium enhancement defect early at emergency department. Under the impression of acute myocardial infarction, emergent coronary angiography revealed left anterior descending artery occlusion. Revascularization was performed and coronary artery dissection was found after thrombus aspiration. Finally, the patient survived after coronary stenting. Perfusion defects of myocardium enhancement on CT after blunt chest trauma can be very helpful to suggest myocardial infarction and facilitate the decision making of emergent procedure. This valuable sign should not be missed during the initial interpretation.

The application of MDCT in the diagnosis of chest trauma.

PubMed

Błasińska-Przerwa, Katarzyna; Pacho, Ryszard; Bestry, Iwona

2013-01-01

Traumas are the third most common cause of death worldwide, after cardiovascular diseases and neoplasms, and the main cause of death of patients under 40 years of age. Contemporary image diagnosis of chest trauma uses chest X-ray (CXR), multidetector computed tomography (MDCT), transthoracic and transoesophageal ultrasound (USG), X-ray angiography and magnetic resonance. The aim of the present study was to evaluate MDCT results in the examination of posttraumatic chest injuries and to compare the results of CXR and MDCT in chosen chest traumatic injuries. The sixty patients with chest trauma included in the study were diagnosed at the Department of Radiology of the Institute of Tuberculosis and Lung Diseases between May 2004 and October 2007. MDCT was performed in all patients. Two groups with different types of injury (blunt or penetrating chest trauma) were distinguished. The analysis of injuries in both groups was conducted depending on the mechanism of trauma. The detection of 20 selected injuries at CXR and MDCT was compared. Moreover, the compatibility of MDCT with the results of intraoperative assessment and bronchoscopy was analysed. The influence of MDCT on the treatment modality was also assessed. History of blunt chest trauma was found in 51 patients (group 1) and of penetrating trauma in 9 patients (group 2). The most frequent injuries among group 1 were lung contusion and rib fractures, and among group 2 it was pericardial hematoma. Compared to MDCT, the sensitivity and specificity of CXR were 66.7 and 58%, respectively. Change of treatment modality was observed after MDCT in 83% of patients. The sensitivity and specificity of MDCT in diagnosing tracheobronchial injury, compared to bronchoscopy, were 72.7% and 100%, respectively. Compatibility of MDCT results and intraoperative assessment was observed in 43% of patients, and the main reason for discrepancy was underdiagnosis of diaphragm injury in MDCT. MDCT was a valuable diagnostic method in recognition of chest trauma, characterized by high sensitivity and specificity in the assessment of life-threatening injures and for depicting tracheal and bronchial injuries. The diagnostic value of CXR was low. The compatibility of MCTD and intraoperative assessment was confirmed, with the exception of diaphragm injures and lung laceration. Change of treatment modality was certified after MDCT in 83% of patients.

The utility of computed tomography as a screening tool for the evaluation of pediatric blunt chest trauma.

PubMed

Markel, Troy A; Kumar, Rajiv; Koontz, Nicholas A; Scherer, L R; Applegate, Kimberly E

2009-07-01

There is a growing concern that computed tomography (CT) is being unnecessarily overused for the evaluation of pediatric patients. The purpose of this study was to analyze the trends and utility of chest CT use compared with chest X-ray (CXR) for the evaluation of children with blunt chest trauma. A 4-year retrospective review was performed for pediatric patients who underwent chest CT within 24 hours of sustaining blunt trauma at a Level-I trauma center. Trends in the use of CT and CXR were documented, and results of radiology reports were analyzed and compared with clinical outcomes. Three hundred thirty-three children, mean age 11 years, had chest CTs, increasing from 5.5% in 2001-2002 to 10.5% in 2004-2005 (p < 0.001). Conversely, in those children who underwent chest CT, the rate of initial CXR use decreased from 84% to 56% during the same period (p < 0.001). Twenty percent of chest CTs had significant positive findings. Six patients underwent emergency surgery for cardiac or arterial injuries, and all demonstrated abnormal findings on CXR or CT scout imaging. When compared with the CT, only 5% of initial CXRs falsely reported normal findings that may have altered management. CT use in children has increased rapidly for the initial evaluation of chest trauma, whereas CXR use has decreased. Despite this trend, CXR remains an acceptable screening tool to analyze which patients may require CT evaluation. A multidisciplinary approach is warranted to develop guidelines that standardize the use of CT and thereby decreases unnecessary radiation exposure to pediatric patients.

What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?

PubMed

Kea, Bory; Gamarallage, Ruwan; Vairamuthu, Hemamalini; Fortman, Jonathan; Lunney, Kevin; Hendey, Gregory W; Rodriguez, Robert M

2013-08-01

Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant. This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance. Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries-primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT. Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management. Copyright © 2013 Elsevier Inc. All rights reserved.

Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases

PubMed Central

2012-01-01

Background Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria. Methods We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality. Results The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%). Conclusions New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis. PMID:22515842

Paediatric trauma care.

PubMed

Sebastian van As, A B

2010-01-01

Childhood trauma has become a major cause of mortality and morbidity, disability and socio-economic burden and it is expected by the World Health Organization (WHO) that by 2020 it will be the number 1 disease globally. The WHO and UNICEF have published their third World Report on Child Injury Prevention in December 2008. A systematic review was performed on the history and magnitude of paediatric trauma worldwide. Additionally exciting developments and new trends were assessed and summarized. Paediatric trauma is a growing field of clinical expertise. New developments include total body digital imaging of children presenting with polytrauma; targeted management of head injuries; conservative management of abdominal injuries in children and diagnostic laparoscopy, including the laparoscopic management of complications following the conservative management of solid organ injuries. Paediatric trauma has long been neglected by the medical profession. In order to deal with it appropriately, it makes sense to adopt the public health approach, requiring that we view child injuries similarly to any other disease or health problem. The greatest gain in our clinical practice with dealing with child injuries will result from a strong focus on primary (preventing the injury), secondary (dealing with the injury in the most efficient manner) as well as tertiary prevention (making sure that children treated for trauma will be appropriately reintegrated within our society). By actively promoting child safety we will not only achieve a most welcome reduction in medical cost and disability, but also the ever-so-much desired decline of avoidable childhood misery and suffering.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations.

PubMed

McNamara, Caitlin; Mironova, Irina; Lehman, Erik; Olympia, Robert P

2017-06-01

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness. Copyright © 2016 Elsevier Inc. All rights reserved.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients With Blunt Chest and Abdominal Trauma.

PubMed

Kokabi, Nima; Harmouche, Elie; Xing, Minzhi; Shuaib, Waqas; Mittal, Pardeep K; Wilson, Kenneth; Johnson, Jamlik-Omari; Nicolaou, Savvas; Khosa, Faisal

2015-05-01

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma. Copyright © 2015 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.

Traumatic Pulmonary Herniation at the Diaphragmatic Junction in a Pediatric Patient: A Rare Complication of Blunt Chest Trauma.

PubMed

Orlik, Kseniya; Simon, Erin Leslie; Hemmer, Carrie; Ramundo, Maria

2016-07-01

We present a case of traumatic intercostal pulmonary herniation in an 11-year-old boy after blunt trauma to the chest, without associated chest wall disruption or pneumothorax. This condition is especially uncommon in children, with only 5 previously reported cases and most occurring after penetrating chest trauma. To date, there are no reports in literature describing traumatic intercostal lung herniation at the diaphragmatic junction with a closed chest cavity in a child. The number of traumatic lung herniation diagnoses may be expanded by a more liberal use of computed tomography when serious injury is suspected. Computed tomography and advanced imaging should be considered in pediatric trauma patients presenting with concern for intrathoracic injury that may not be seen on plain film. Traumatic blunt intrathoracic and intra-abdominal injuries in the pediatric population that are within proximity of diaphragmatic insertion should be thoroughly evaluated to rule out diaphragmatic injury. As in our case, invasive surgical intervention such as thoracoscopy may be necessary.

Is it adequate to carry out a chest-CT in patients with mild-moderate chest trauma?

PubMed

García de Pereda de Blas, V; Carreras Aja, M; Carbajo Azabal, S; Arana-Arri, E

2017-10-12

Mild-moderate blunt chest trauma is defined as a blunt chest trauma that is not caused by a high-energy mechanism, causing thoracic tenderness with or without rib fractures and that has no immediate life-threatening consequences for the patient. It is a frequent clinical situation in the emergency department. The most common radiological techniques that are used in this context are chest X-ray and thoracic computed tomography (CT). The CT scan is set as the gold standard. However, there are no current clinical-radiological guidelines that establish the adequacy of the requests of the CT scan. Therefore, we decided to search for evidence-based recommendations to improve the adequacy of the chest X-ray and CT scan in our daily practice in order to reduce the costs and avoid unnecessary radiation exposure. Copyright © 2017 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.

Latent Tricuspid Valve Rupture after Motor Vehicle Accident and Routine Echocardiography in All Chest-Wall Traumas

PubMed Central

Khurana, Suchi; Puri, Rishi; Wong, Dennis; Dundon, Benjamin K.; Brown, Michael A.; Worthley, Matthew I.; Worthley, Stephen G.

2009-01-01

Blunt chest-wall trauma is common; however, resultant tricuspid valve rupture is rare and can be subtle in its presentation. Transthoracic echocardiography plays a key role in diagnosis. Herein, we report the case of a 42-year-old woman who sustained substantial chest-wall trauma in a high-speed motor vehicle accident. She presented a week later with symptoms of right-heart failure, secondary to flail tricuspid valve leaflets and torrential tricuspid regurgitation. The case of this patient highlights the importance of early diagnosis and elicits discussion of the mechanisms that can underlie delayed tricuspid valve rupture. Because the clinical diagnosis of tricuspid valve rupture can be difficult, we believe that echocardiography should be used early and, if necessary, repeatedly in all patients who sustain blunt chest-wall trauma. PMID:20069094

Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan.

PubMed

Nagarsheth, Khanjan; Kurek, Stanley

2011-04-01

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.

CIVILIAN GUNSHOT WOUNDS TO THE CHEST: A CLINICOPATHOLOGICAL ANALYSIS OF AN ANNUAL CASELOAD AT A LEVEL 1 TRAUMA CENTRE.

PubMed

Meijering, V M; Hattam, A T; Navsaria, P H; Nicol, A J; Edu, S

2017-06-01

Gunshot wounds (GSW) to the chest are common presentations to trauma centres in South Africa. The clinical management and outcome of GSW to the chest are significantly altered by missile trajectory and the associated anatomical structures injured making them challenging injuries to treat. Currently, the management of GSW chest is based on scant evidence and treatment is typically according to algorithms based largely on the anecdotal experience of high volume institutions and experienced clinicians. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated for the year 2015 for all patients with GSW chest. The data was then analysed using descriptive statistics. A total of 141 patients with GSW to the chest were admitted to the Trauma Centre with a median age of 26 years. More than half of the patients, 53. 2% (n = 75) sustained an isolated GSW to the chest. Overall, 29.1% (n = 41) patients sustained a thoracoabdominal injury, which accounts for a significant higher amount of emergency surgeries compared to patients with non thoracoabdominal injuries (54% vs 15%, p = < 0.01). 9.2% (n = 13) of all patients required an emergency thoracotomy or emergency chest surgery of which 5 patients survived. Overall mortality was 7.1% (n = 10) of which 5 patients died from a thoracic cause. Civilian GSW to the chest are common injuries seen in Cape Town, often with concomitant injuries leading to increased morbidity. Significantly more emergency surgeries were done in patients with thoracoabdominal injury. Overall few patients needed chest-related emergency operative intervention (9.2%) with a survival rate of 38.5%. Overall mortality of patients with GSW chest who reached the hospital was 7.1% of whom 50% died from a thoracic cause.

CIVILIAN GUNSHOT WOUNDS TO THE CHEST: A CLINICOPATHOLOGICAL ANALYSIS OF AN ANNUAL CASELOAD AT A LEVEL 1 TRAUMA CENTRE.

PubMed

Meijering, V M; Hattam, A T

2017-06-01

Gunshot wounds (GSW) to the chest are common presentations to trauma centres both in South Africa and internationally. The clinical management and outcome of GSW to the chest are significantly altered by missile trajectory and the associated anatomical structures injured making them challenging injuries to treat. Currently, the management of GSW chest is based on scant evidence and treatment is typically according to algorithms based largely on the anecdotal experience of high volume institutions and experienced clinicians. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated for the year 2015 for all patients with GSW chest. The data was then analysed using descriptive statistics. A total of 141 patients with GSW to the chest were admitted to the Trauma Centre with a median age of 26 years . More than half of the patients, 53.2% (n = 75), sustained an isolated GSW to the chest. Overall, 29.1% (n = 41) patients sustained thoraco-abdominal injury, which accounts for a significant higher number of emergency surgeries compared to patients with non thoraco-abdominal injury (54% vs 15%, p = < 0.01). 9.2% (n = 13) of all patients required an emergency thoracotomy or emergency chest surgery (resp. 3.5% and 5.7%) of which 5 patients survived. Overall mortality was 7.1% (n = 10) of which 5 patients died from a thoracic cause. Civilian GSW to the chest are common injuries seen in Cape Town, often with concomitant injuries leading to increased morbidity. Significantly more emergency surgeries were done in patients with thoraco-abdominal injury. Overall few patients needed chest-related emergency operative intervention (9.2%) with a survival rate of 38.5%. Overall mortality of patients with GSW chest who reached the hospital was 7.1% of whom 50% died from a thoracic cause.

Chest trauma in children, single center experience.

PubMed

Ismail, Mohamed Fouad; al-Refaie, Reda Ibrahim

2012-10-01

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating trauma (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%), flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was 7.2% and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality. Copyright © 2011 SEPAR. Published by Elsevier España, S.L. All rights reserved.

Computerised lung sound analysis to improve the specificity of paediatric pneumonia diagnosis in resource-poor settings: protocol and methods for an observational study

PubMed Central

Gilman, Robert H; Tielsch, James M; Steinhoff, Mark; Figueroa, Dante; Rodriguez, Shalim; Caffo, Brian; Tracey, Brian; Elhilali, Mounya; West, James; Checkley, William

2012-01-01

Introduction WHO case management algorithm for paediatric pneumonia relies solely on symptoms of shortness of breath or cough and tachypnoea for treatment and has poor diagnostic specificity, tends to increase antibiotic resistance. Alternatives, including oxygen saturation measurement, chest ultrasound and chest auscultation, exist but with potential disadvantages. Electronic auscultation has potential for improved detection of paediatric pneumonia but has yet to be standardised. The authors aim to investigate the use of electronic auscultation to improve the specificity of the current WHO algorithm in developing countries. Methods This study is designed to test the hypothesis that pulmonary pathology can be differentiated from normal using computerised lung sound analysis (CLSA). The authors will record lung sounds from 600 children aged ≤5 years, 100 each with consolidative pneumonia, diffuse interstitial pneumonia, asthma, bronchiolitis, upper respiratory infections and normal lungs at a children's hospital in Lima, Peru. The authors will compare CLSA with the WHO algorithm and other detection approaches, including physical exam findings, chest ultrasound and microbiologic testing to construct an improved algorithm for pneumonia diagnosis. Discussion This study will develop standardised methods for electronic auscultation and chest ultrasound and compare their utility for detection of pneumonia to standard approaches. Utilising signal processing techniques, the authors aim to characterise lung sounds and through machine learning, develop a classification system to distinguish pathologic sounds. Data will allow a better understanding of the benefits and limitations of novel diagnostic techniques in paediatric pneumonia. PMID:22307098

Scapular Fractures in Blunt Chest Trauma – Self-Experience Study

PubMed Central

Al-Sadek, Tabet A.; Niklev, Desislav; Al-Sadek, Ahmed; Al-Sadek, Lina

2016-01-01

AIM: The aim of this retrospective study was to report the scapular fractures in patients with blunt chest trauma and to present the type and the frequency of associated thoracic injuries. MATERIAL AND METHODS: Nine patients with fractures of the scapula were included in the study. The mechanisms of the injury, the type of scapular fractures and associated thoracic injuries were analysed. RESULTS: Scapular fractures were caused by high-energy blunt chest trauma. The body of the scapula was fractured in all scapular fractures. In all cases, scapular fractures were associated with other thoracic injuries (average 3.25/per case). Rib fractures were present in eight patients, fractured clavicula - in four cases, the affection of pleural cavity - in eight of the patients and pulmonary contusion in all nine cases. Eight patients were discharged from the hospital up to the 15th day. One patient had died on the 3rd day because of postconcussional lung oedema. CONCLUSIONS: The study confirms the role of scapular fractures as a marker for the severity of the chest trauma (based on the number of associated thoracic injuries), but doesn’t present scapular fractures as an indicator for high mortality in blunt chest trauma patients. PMID:28028415

[Community acquired pneumonia in children: Treatment of complicated cases and risk patients. Consensus statement by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Chest Diseases (SENP)].

PubMed

Moreno-Pérez, D; Andrés Martín, A; Tagarro García, A; Escribano Montaner, A; Figuerola Mulet, J; García García, J J; Moreno-Galdó, A; Rodrigo Gonzalo de Lliria, C; Saavedra Lozano, J

2015-09-01

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

Open pneumothorax resulting from blunt thoracic trauma: a case report.

PubMed

McClintick, Colleen M

2008-01-01

Cases of open pneumothorax have been documented as early as 326 BC. Until the last 50 years, understanding of the epidemiology and treatment of penetrating chest trauma has arisen from military surgery. A better understanding of cardiopulmonary dynamics, advances in ventilatory support, and improvement in surgical technique have drastically improved treatment and increased the survival rate of patients with penetrating thoracic trauma. Open pneumothorax is rare in blunt chest trauma, but can occur when injury results in a substantial loss of the chest wall. This case study presents an adolescent who sustained a large open pneumothorax as a result of being run over by a car. Early and appropriate surgical intervention coupled with coordinated efforts by all members of the trauma team resulted in a positive outcome for this patient.

The Use of Chest Computed Tomographic Angiography in Blunt Trauma Pediatric Population.

PubMed

Hasadia, Rabea; DuBose, Joseph; Peleg, Kobi; Stephenson, Jacob; Givon, Adi; Kessel, Boris

2018-02-05

Blunt chest trauma in children is common. Although rare, associated major thoracic vascular injuries (TVIs) are lethal potential sequelae of these mechanisms. The preferred study for definitive diagnosis of TVI in stable patients is computed tomographic angiography imaging of the chest. This imaging modality is, however, associated with high doses of ionizing radiation that represent significant carcinogenic risk for pediatric patients. The aim of the present investigation was to define the incidence of TVI among blunt pediatric trauma patients in an effort to better elucidate the usefulness of computed tomographic angiography use in this population. A retrospective cohort study was conducted including all blunt pediatric (age < 14 y) trauma victims registered in Israeli National Trauma Registry maintained by Gertner Institute for Epidemiology and Health Policy Research between the years 1997 and 2015. Data collected included age, sex, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, and incidence of chest named vessel injuries. Statistical analysis was performed using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC). Among 433,325 blunt trauma victims, 119,821patients were younger than 14 years. Twelve (0.0001%, 12/119821) of these children were diagnosed with TVI. The most common mechanism in this group was pedestrian hit by a car. Mortality was 41.7% (5/12). Thoracic vascular injury is exceptionally rare among pediatric blunt trauma victims but does contribute to the high morbidity and mortality seen with blunt chest trauma. Computed tomographic angiography, with its associated radiation exposure risk, should not be used as a standard tool after trauma in injured children. Clinical protocols are needed in this population to minimize radiation risk while allowing prompt identification of life-threatening injuries.

Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT).

PubMed

Rodriguez, Robert M; Langdorf, Mark I; Nishijima, Daniel; Baumann, Brigitte M; Hendey, Gregory W; Medak, Anthony J; Raja, Ali S; Allen, Isabel E; Mower, William R

2015-10-01

Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.

Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: report of a case.

PubMed

Yeh, Chun-Chieh; Hsieh, Chi-Hsun; Wang, Yu-Chun; Chung, Ping-Kuei; Chen, Ray-Jade

2009-01-01

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.

A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture

PubMed Central

Jin, Han-Young; Seo, Jeong-Sook; Yang, Tae-Hyun; Kim, Dae-Kyeong; Kim, Dong-Kie; Kim, Ung; Seol, Sang-Hoon; Kim, Doo-Il; Kim, Dong-Soo

2011-01-01

Traumatic tricuspid regurgitation is a rare complication of blunt chest trauma. With the increase in the number of automobile accidents, traumatic tricuspid regurgitation has become an important problem after blunt chest trauma. It has been reported more frequently because of better diagnostic procedures and a better understanding of the pathology. The early diagnosis of traumatic tricuspid regurgitation is important because traumatic tricuspid injury could be effectively corrected with reparative techniques, early operation is considered to relieve symptoms and to prevent right ventricular dysfunction. Echocardiography can reveal the cause and severity of regurgitation. We experienced a case of tricuspid regurgitation after blunt chest trauma early diagnosis and valve repair were performed. This case reminds the physicians in the emergency department should be aware of this potential complication following non-penetrating chest trauma and echocardiography is useful and should play an early role. PMID:21519493

Evaluation of chest and abdominal injuries in trauma patients hospitalized in the surgery ward of poursina teaching hospital, guilan, iran.

PubMed

Hemmati, Hossein; Kazemnezhad-Leili, Ehsan; Mohtasham-Amiri, Zahra; Darzi, Ali Asghar; Davoudi-Kiakalayeh, Ali; Dehnadi-Moghaddam, Anoush; Kouchakinejad-Eramsadati, Leila

2013-01-01

Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients. This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran. In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire. In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%). Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health.

Evaluation of Chest and Abdominal Injuries in Trauma Patients Hospitalized in the Surgery Ward of Poursina Teaching Hospital, Guilan, Iran

PubMed Central

Hemmati, Hossein; Kazemnezhad-Leili, Ehsan; Mohtasham-Amiri, Zahra; Darzi, Ali Asghar; Davoudi-Kiakalayeh, Ali; Dehnadi-Moghaddam, Anoush; Kouchakinejad-Eramsadati, Leila

2013-01-01

Background Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients. Objectives This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran. Patients and Methods In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire. Results In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%). Conclusions Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health. PMID:24396771

Blunt chest trauma: bony injury in the thorax.

PubMed

Zreik, Nasri H; Francis, Irene; Ray, Arun; Rogers, Benedict A; Ricketts, David M

2016-02-01

The management of blunt chest trauma is an evolving concept with no clear current guidelines. This article explores the bony injuries associated with this, focusing on rib fractures and flail segments and the themes around investigation and best management.

Anteroposterior chest radiograph vs. chest CT scan in early detection of pneumothorax in trauma patients.

PubMed

Omar, Hesham R; Mangar, Devanand; Khetarpal, Suneel; Shapiro, David H; Kolla, Jaya; Rashad, Rania; Helal, Engy; Camporesi, Enrico M

2011-09-27

Pneumothorax is a common complication following blunt chest wall trauma. In these patients, because of the restrictions regarding immobilization of the cervical spine, Anteroposterior (AP) chest radiograph is usually the most feasible initial study which is not as sensitive as the erect chest X-ray or CT chest for detection of a pneumothorax. We will present 3 case reports which serve for better understanding of the entity of occult pneumothorax. The first case is an example of a true occult pneumothorax where an initial AP chest X-ray revealed no evidence of pneumothorax and a CT chest immediately performed revealed evidence of pneumothorax. The second case represents an example of a missed rather than a truly occult pneumothorax where the initial chest radiograph revealed clues suggesting the presence of pneumothorax which were missed by the reading radiologist. The third case emphasizes the fact that "occult pneumothorax is predictable". The presence of subcutaneous emphesema and pulmonary contusion should call for further imaging with CT chest to rule out pneumothorax. Thoracic CT scan is therefore the "gold standard" for early detection of a pneumothorax in trauma patients. This report aims to sensitize readers to the entity of occult pneumothorax and create awareness among intensivists and ER physicians regarding the proper diagnosis and management.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

PubMed

Nummela, Mari T; Bensch, Frank V; Pyhältö, Tuomo T; Koskinen, Seppo K

2018-02-01

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ 2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Development of the major trauma case review tool.

PubMed

Curtis, Kate; Mitchell, Rebecca; McCarthy, Amy; Wilson, Kellie; Van, Connie; Kennedy, Belinda; Tall, Gary; Holland, Andrew; Foster, Kim; Dickinson, Stuart; Stelfox, Henry T

2017-02-28

As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure. Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool. The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters. This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care. This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

ACR appropriateness criteria blunt chest trauma.

PubMed

Chung, Jonathan H; Cox, Christian W; Mohammed, Tan-Lucien H; Kirsch, Jacobo; Brown, Kathleen; Dyer, Debra Sue; Ginsburg, Mark E; Heitkamp, Darel E; Kanne, Jeffrey P; Kazerooni, Ella A; Ketai, Loren H; Ravenel, James G; Saleh, Anthony G; Shah, Rakesh D; Steiner, Robert M; Suh, Robert D

2014-04-01

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiography's accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Flail tricuspid valve secondary to blunt chest trauma

PubMed Central

Srinivas, Sunil Kumar; Patil, Shivanand; Ramalingam, Rangaraj; Bhairappa, Shivakumar

2012-01-01

A 78-year-old man admitted with complaints of breathlessness of 1 year and typical chest pain of 2 months duration. He had a blunt chest trauma 7 years back. Transthoracic echocardiography revealed severe tricuspid regurgitation due to a flail anterior leaflet of the tricuspid valve. It also revealed global left ventricular dysfunction. Flail tricuspid valve causing severe regurgitation is usually due to mechanical trauma. Since it is well tolerated for years, the diagnosis may be delayed or missed entirely. Echocardiography has allowed easier diagnosis of this condition resulting in earlier and, hence, more effective treatment. PMID:22922931

[Automatic mechanical chest compression during helicopter transportation].

PubMed

Kyrval, Helle S; Ahmad, Khalil

2010-11-15

We describe a case story with a drowned, hypothermic trauma patient treated with an automatic mechanical chest compression device during helicopter transportation to a trauma center. After falling from a 25 meter high bridge into 2 °C water, she was rescued lifeless 17 minutes later. Advanced life support was initiated. During transport by a rescue helicopter, chest compressions were effectively provided by Lund University Cardiopulmonary Assist System (LUCAS). Upon arrival to a trauma centre approx. 60 minutes later, the patient was treated with extracorporal circulation and rewarmed. She was eventually discharged to her home with minor loss of cerebral function.

CT detection of occult pneumothorax in head trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tocino, I.M.; Miller, M.H.; Frederick, P.R.

1984-11-01

A prospective evaluation for occult pneumothorax was performed in 25 consecutive patients with serious head trauma by combining a limited chest CT examination with the emergency head CT examination. Of 21 pneuomothoraces present in 15 patients, 11 (52%) were found only by chest CT and were not identified clinically or by supine chest radiograph. Because of pending therapeutic measures, chest tubes were placed in nine of the 11 occult pneumothoraces, regardless of the volume. Chest CT proved itself as the most sensitive method for detection of occult pneumothorax, permitting early chest tube placement to prevent transition to a tension pneumothoraxmore » during subsequent mechanical ventilation or emergency surgery under general anesthesia.« less

Pseudocalcification on chest CT scan.

PubMed

Tiruvoipati, R; Balasubramanian, S K; Entwisle, J J; Firmin, R K; Peek, G J

2007-07-01

Liquid ventilation with perfluorocarbons is used in severe respiratory failure that cannot be managed by conventional methods. Very little is known about the use of liquid ventilation in paediatric patients with respiratory failure and there are no reports describing the distribution and excretion of perfluorocarbons in paediatric patients with severe respiratory failure. The aim of this report is to highlight the prolonged retention of perfluorocarbons in a paediatric patient, mimicking pulmonary calcification and misleading the interpretation of the chest CT scan. A 10-year-old girl was admitted to our intensive care unit with severe respiratory failure due to miliary tuberculosis. Extracorporeal membrane oxygenation (ECMO) was used to support gas exchange and partial liquid ventilation (PLV) with perfluorodecalin was used to aid in oxygenation, lavage the lungs and clear thick secretions. The patient developed a pneumothorax (fluorothorax) on the next day and PLV was discontinued. Multiple bronchoalveolar lavages were performed to clear thick secretions. With no improvement in lung function over the next month a CT scan of the chest was performed. This revealed extensive pulmonary fibrosis and multiple high attenuation lesions suggestive of pulmonary calcification. To exclude perfluorodecalin as the cause for high attenuation lesions, a sample of perfluorodecalin was scanned to estimate the Hounsfield unit density, which was similar to the density of high attenuation lesions on chest CT scan. High-density opacification should be interpreted with caution, especially following liquid ventilation.

Occult pneumothorax in trauma patients: should this be sought in the focused assessment with sonography for trauma examination?

PubMed

Tam, Michael M K

2005-01-01

At present, CT scan is the gold standard for detecting occult traumatic pneumothorax not apparent on supine chest X-ray radiograph. Recently there were suggestions to expand focused assessment with sonography for trauma (FAST) to include thoracic ultrasound for detecting pneumothorax. The aim of the present study is to determine the incidence of occult pneumothorax (as shown by CT) in the subgroup of trauma patients undergoing FAST. Review of all trauma patients with FAST done from 1 June 2001 to 31 October 2002. Incidence of occult pneumothorax as diagnosed by CT was determined. Patients were not counted as having true occult pneumothorax if they had chest drains inserted before arrival or imaging studies. Selected clinical findings were tested for association with occult pneumothorax. In total, 143 patients underwent FAST, of whom 137 (95.8%) had chest X-ray examination performed. Of the 137 patients 59 required CT abdomen and/or thorax. Occult pneumothorax was found in three patients (2.1%). A history of thorax and/or abdominal injury plus one or more of: (i) mechanisms potentially causing major trauma; (ii) abnormal chest examination; and (iii) chest X-ray radiograph abnormality in the absence of pneumothorax, was significantly associated with the presence of occult pneumothorax (P = 0.03, Fisher's exact test; sensitivity: 100%; specificity: 71%; likelihood ratio: 3.42). The incidence of occult pneumothorax in the subgroup of trauma patients undergoing FAST is low. It implies that routine screening for its presence by adding thoracic ultrasound to FAST is unnecessary. Identifying those at risk of occult pneumothorax for further investigation appeared feasible.

[Chest Injury and its Surgical Treatment in Polytrauma Patients. Five-Year Experience].

PubMed

Vodička, J; Doležal, J; Vejvodová, Š; Šafránek, J; Špidlen, V; Třeška, V

2016-01-01

PURPOSE OF THE STUDY Thoracic trauma, one of the most frequent injuries in patients with multiple traumata, is found in 50 to 80% of these patients and it is crucial for the patient's prognosis. It accounts for 25% of all death from polytraumatic injuries. The aim of this retrospective study was an analysis of the occurrence of chest injuries in polytrauma patients and their surgical treatment in the Trauma Centre or Department of Surgery of the University Hospital Pilsen in a five-year period. MATERIAL AND METHODS Patients with injuries meeting the definition of polytrauma and an Injury Severity Score (ISS) ≥16 were included. The demographic characteristics, mechanism of multiple trauma, ISS value and chest injury were recorded in each patient. The number of injured patients in each year of the study was noted. In the patients with chest injury, the type of injury and method of treatment were assessed. The therapy was further analysed including its timing. The number of deaths due to polytrauma involving chest injury, the cause of death and its time in relation to the patient's admission to the Trauma Centre were evaluated. RESULTS In the period 2010-14, 513 polytrauma patients were treated; of them 371 (72.3%) were men with an average age of 40.5 years. The most frequent cause of injury was a traffic accident (74%). The average ISS of the whole group was 35 points. Chest injury was diagnosed in 469 patients (91.4%) of whom only five (1.1%) had penetrating injury. Pulmonary contusion was most frequent (314 patients; 67%). A total of 212 patients with chest injury underwent surgery (45.2%); urgent surgery was performed in 143 (67.5%), acute surgery in 49 (23.1%) and delayed surgery in 63 (29.7%) patients. Chest drainage was the major surgical procedure used in the whole group. Of 61 patients who died, 52 had chest injury. In this subgroup the most frequent cause of death was decompensated traumatic shock (26 patients; 50%). In the whole group, 32 polytrauma patients died within 24 hours of injury (61.5%). CONCLUSIONS Chest injury, almost always blunt, is often diagnosed in polytrauma patients. A prevalent cause of multiple trauma is a traffic accident. Chest injury most frequently involves pulmonary contusion. Nearly half of chest injuries require surgery, of which 2/3 are urgent procedures. The procedure most frequently performed in polytrauma patients with chest injury is chest drainage and this is also a sufficient procedure in 75% of surgically treated patients. polytrauma, chest injury, pulmonary contusion, surgical treatment, chest drainage.

Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT.

PubMed

Davies, J; Cross, S; Evanson, J

2016-09-01

To determine the potential effect of changes to the National Institute for Health and Care Excellence (NICE) guidelines to the use of computed tomography (CT) in the assessment of suspected paediatric cervical spine (c-spine) injury. A 5 year retrospective study was conducted of c-spine imaging in paediatric (<10 years) patients presenting following blunt trauma at a Level 1 trauma centre in London. All patients under the age of 10 years who underwent any imaging of the c-spine following blunt trauma were included. Clinical data relating to the presenting signs and symptoms were obtained from the retrospective review of electronic records and paper notes. This was then applied to the previous NICE guideline (CG56) and to the new NICE guideline (CG176). Patients with incomplete data were excluded. Two hundred and seventy-eight patients <10 years underwent imaging of the c-spine following blunt trauma. Two hundred and seventy (97.12%) examinations had complete data and were included in further analysis. One hundred and forty-nine (55.19%) met the criteria for a CT of the c-spine under NICE CG56, whereas 252 (93.33%) met the updated NICE CG176 criteria for c-spine CT. Five (1.85%) patients had a c-spine injury and met the criteria under both CG56 and CG176 NICE guidelines. Recent changes to NICE Head Injury Guidelines relating to radiological assessment of paediatric c-spine following blunt trauma are likely to result in an increased usage of CT as the initial radiological investigation over plain radiographs, without an apparent increase in specificity in the present series. Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT)

PubMed Central

Rodriguez, Robert M.; Langdorf, Mark I.; Nishijima, Daniel; Baumann, Brigitte M.; Hendey, Gregory W.; Medak, Anthony J.; Raja, Ali S.; Allen, Isabel E.; Mower, William R.

2015-01-01

Background Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. Methods and Findings From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients—6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 20.8% (95% CI 19.2%–22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%–100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%–96.9%), a specificity of 25.5% (95% CI 23.5%–27.5%), and a NPV of 93.9% (95% CI 91.5%–95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 31.7% (95% CI 29.9%–33.5%), and a NPV of 99.9% (95% CI 99.3%–100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%–92.8%), a specificity of 37.9% (95% CI 35.8%–40.1%), and a NPV of 91.8% (95% CI 89.7%–93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. Conclusions We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%–37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population. PMID:26440607

Dose reduction with adaptive statistical iterative reconstruction for paediatric CT: phantom study and clinical experience on chest and abdomen CT.

PubMed

Gay, F; Pavia, Y; Pierrat, N; Lasalle, S; Neuenschwander, S; Brisse, H J

2014-01-01

To assess the benefit and limits of iterative reconstruction of paediatric chest and abdominal computed tomography (CT). The study compared adaptive statistical iterative reconstruction (ASIR) with filtered back projection (FBP) on 64-channel MDCT. A phantom study was first performed using variable tube potential, tube current and ASIR settings. The assessed image quality indices were the signal-to-noise ratio (SNR), the noise power spectrum, low contrast detectability (LCD) and spatial resolution. A clinical retrospective study of 26 children (M:F = 14/12, mean age: 4 years, range: 1-9 years) was secondarily performed allowing comparison of 18 chest and 14 abdominal CT pairs, one with a routine CT dose and FBP reconstruction, and the other with 30 % lower dose and 40 % ASIR reconstruction. Two radiologists independently compared the images for overall image quality, noise, sharpness and artefacts, and measured image noise. The phantom study demonstrated a significant increase in SNR without impairment of the LCD or spatial resolution, except for tube current values below 30-50 mA. On clinical images, no significant difference was observed between FBP and reduced dose ASIR images. Iterative reconstruction allows at least 30 % dose reduction in paediatric chest and abdominal CT, without impairment of image quality. • Iterative reconstruction helps lower radiation exposure levels in children undergoing CT. • Adaptive statistical iterative reconstruction (ASIR) significantly increases SNR without impairing spatial resolution. • For abdomen and chest CT, ASIR allows at least a 30 % dose reduction.

Failure rate of prehospital chest decompression after severe thoracic trauma.

PubMed

Kaserer, Alexander; Stein, Philipp; Simmen, Hans-Peter; Spahn, Donat R; Neuhaus, Valentin

2017-03-01

Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques. In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied. In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization. Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission. Copyright © 2016. Published by Elsevier Inc.

"Anterior convergent" chest probing in rapid ultrasound transducer positioning versus formal chest ultrasonography to detect pneumothorax during the primary survey of hospital trauma patients: a diagnostic accuracy study.

PubMed

Ziapour, Behrad; Haji, Houman Seyedjavady

2015-01-01

Occult pneumothorax represents a diagnostic pitfall during the primary survey of trauma patients, particularly if these patients require early positive pressure ventilation. This study investigated the accuracy of our proposed rapid model of ultrasound transducer positioning during the primary survey of trauma patients after their arrival at the hospital. This diagnostic trial was conducted over 12 months and was based on the results of 84 ultrasound (US) exams performed on patients with severe multiple trauma. Our index test (US) was used to detect pneumothorax in four pre-defined locations on the anterior of each hemi-thorax using the "Anterior Convergent" approach, and its performance was limited to the primary survey. Consecutively, patients underwent chest-computed tomography (CT) with or without chest radiography. The diagnostic findings of both chest radiography and chest ultrasounds were compared to the gold-standard test (CT). The diagnostic sensitivity was 78 % for US and 36.4 % for chest radiography (p < 0.001); the specificity was 92 % for US and 98 % for chest radiography (not significant); the positive predictive values were 74 % for US and 80 % for chest radiography (not significant); the negative predictive values were 94 % for US and 87 % for chest radiography (not significant); the positive likelihood ratio was 10 for US and 18 for chest radiography (p = 0.007); and the negative likelihood ratio was 0.25 for US and 0.65 for chest radiography (p = 0.001). The mean required time for performing the new method was 64 ± 10 s. An absence of the expected diffused dynamic view among ultrasound images obtained from patients with pneumothorax was also observed. We designated this phenomenon "Gestalt Lung Recession." "Anterior convergent" chest US probing represents a brief but efficient model that provides clinicians a safe and accurate exam and adequate resuscitation during critical minutes of the primary survey without interrupting other medical staff activities taking place around the trauma patient. The use of the new concept of "Gestalt Lung Recession" instead of the absence of "lung sliding" might improve the specificity of US in detecting pneumothorax.

Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma.

PubMed

Wilkerson, R Gentry; Stone, Michael B

2010-01-01

Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma. (c) 2010 by the Society for Academic Emergency Medicine.

Thoracic Trauma: Which Chest Tube When and Where?

PubMed

Molnar, Tamas F

2017-02-01

Clinical suspicion of hemo/pneumothorax: when in doubt, drain the chest. Stable chest trauma with hemo/pneumothorax: drain and wait. Unstable patient with dislocated trachea must be approached with drain in hand and scalpel ready. Massive hemo/pneumothorax may be controlled by drainage alone. The surgeon should not hesitate to open the chest if too much blood drains over a short period. The chest drainage procedure does not end with the last stitch; the second half of the match is still ahead. The drained patient is in need of physiotherapy and proper pain relief with an extended pleural space: control the suction system. Copyright © 2016 Elsevier Inc. All rights reserved.

Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery.

PubMed

Kulla, Martin; Helm, Matthias; Lefering, Rolf; Walcher, Felix

2012-06-01

The aim of this study was to determine whether prehospital endotracheal intubation (ETI) and chest tube placement is unnecessarily time consuming in severely injured patients. A retrospective, multicentre study including all adult patients (ISS ≥9; 2002-7) of the Trauma Registry of the German Society of Trauma Surgery who were not secondarily transferred to a trauma centre and received a definitive airway and a chest tube. Creating four groups: AA (n=963) receiving ETI and chest tube on scene, AB (n=1547) ETI performed in the prehospital setting but chest tubing later in the emergency department (ED) and BB (n=640) receiving both procedures in the ED. The BA collective (ETI performed in the ED, but chest tubing on scene) was excluded from the study because of the small sample size (n=41). The trauma resuscitation time (TRT), demographic data, injuries, treatment and outcome of the remaining three collectives were compared. The prehospital TRT of the AA collective was longer than the AB and BB subgroups (80±37 min vs 77±44 min 65±46 min; p<0.01). Although the AA and AB subgroups were more severely injured (ISS 35±15 vs 38±15 vs 31±12; p<0.01) and showed poorer vital parameters on scene, the overall TRT (accident until end of ED treatment) were equal for all three groups (152±59 min vs 151±62 min vs 148±68 min; p=0.07). The TRISS adjusted mortality was also equal in all three groups. In a physician-based emergency medical service, prehospital ETI and chest tube placement do not prolong the total TRT of severely injured patients.

Acute fatal coronary artery dissection following exercise-related blunt chest trauma.

PubMed

Barbesier, Marie; Boval, Catherine; Desfeux, Jacques; Lebreton, Catherine; Léonetti, Georges; Piercecchi, Marie-Dominique

2015-01-01

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life-threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43-year-old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma. © 2014 American Academy of Forensic Sciences.

Multislice CT of the head and body routine scans: Are scanning protocols adjusted for paediatric patients?

PubMed Central

Sun, Z; Al Ghamdi, KS; Baroum, IH

2012-01-01

Purpose: To investigate whether the multislice CT scanning protocols of head, chest and abdomen are adjusted according to patient’s age in paediatric patients. Materials and Methods: Multislice CT examination records of paediatric patients undergoing head, chest and abdomen scans from three public hospitals during a one-year period were retrospectively reviewed. Patients were categorised into the following age groups: under 4 years, 5–8 years, 9–12 years and 13–16 years, while the tube current was classified into the following ranges: < 49 mA, 50–99 mA, 100–149 mA, 150–199 mA, > 200 mA and unknown. Results: A total of 4998 patient records, comprising a combination of head, chest and abdomen CT scans, were assessed, with head CT scans representing nearly half of the total scans. Age-based adjusted CT protocols were observed in most of the scans with higher tube current setting being used with increasing age. However, a high tube current (150–199 mA) was still used in younger patients (0–8 years) undergoing head CT scans. In one hospital, CT protocols remained constant across all age groups, indicating potential overexposure to the patients. Conclusion: This analysis shows that paediatric CT scans are adjusted according to the patient’s age in most of the routine CT examinations. This indicates increased awareness regarding radiation risks associated with CT. However, high tube current settings are still used in younger patient groups, thus, optimisation of paediatric CT protocols and implementation of current guidelines, such as age-and weight-based scanning, should be recommended in daily practice. PMID:22970059

Compliance with barrier precautions during paediatric trauma resuscitations.

PubMed

Kelleher, Deirdre C; Carter, Elizabeth A; Waterhouse, Lauren J; Burd, Randall S

2013-03-01

Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations. Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance. Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p<0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p<0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR=3.97 [95% CI: 1.35-11.70], p=0.01), during resuscitations triaged to the highest activation level (OR=2.61 [95% CI: 1.34-5.10], p=0.005), and among team members present before patient arrival (OR=4.14 [95% CI: 2.29-7.39], p<0.001). Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Mitral Perivalvular Leak after Blunt Chest Trauma: A Rare Cause of Severe Subacute Mitral Regurgitation.

PubMed

Marchese, Nicola; Facciorusso, Antonio; Vigna, Carlo

2015-12-01

Blunt chest trauma is a very rare cause of valve disorder. Moreover, mitral valve involvement is less frequent than is aortic or tricuspid valve involvement, and the clinical course is usually acute. In the present report, we describe the case of a 49-year-old man with a perivalvular mitral injury that became clinically manifest one year after a violent, nonpenetrating chest injury. This case is atypical in regard to the valve involved (isolated mitral damage), the injury type (perivalvular leak in the absence of subvalvular abnormalities), and the clinical course (interval of one year between trauma and symptoms).

The number of displaced rib fractures is more predictive for complications in chest trauma patients.

PubMed

Chien, Chih-Ying; Chen, Yu-Hsien; Han, Shih-Tsung; Blaney, Gerald N; Huang, Ting-Shuo; Chen, Kuan-Fu

2017-02-28

Traumatic rib fractures can cause chest complications that need further treatment and hospitalization. We hypothesized that an increase in the number of displaced rib fractures will be accompanied by an increase in chest complications. We retrospectively reviewed the trauma registry between January 2013 and May 2015 in a teaching hospital in northeastern Taiwan. Patients admitted with chest trauma and rib fractures without concomitant severe brain, splenic, pelvic or liver injuries were included. The demographic data, such as gender, age, the index of coexistence disease, alcohol consumption, trauma mechanisms were analyzed as potential predictors of pulmonary complications. Pulmonary complications were defined as pneumothorax, hemothorax, flail chest, pulmonary contusion, and pneumonia. In the 29 months of the study period, a total of 3151 trauma patients were admitted to our hospital. Among them, 174 patients were enrolled for final analysis. The most common trauma mechanism was road traffic accidents (58.6%), mainly motorbike accidents (n = 70, 40.2%). Three or more displaced rib fractures had higher specificity for predicting complications, compared to three or more total rib fractures (95.5% vs 59.1%). Adjusting the severity of chest trauma using TTSS and Ribscore by multivariable logistic regression analysis, we found that three or more rib fractures or any displaced rib fracture was the most significant predictor for developing pulmonary complication (aOR: 5.49 95% CI: 1.82-16.55). Furthermore, there were 18/57 (31.6%) patients with fewer than three ribs fractures developed pulmonary complications. In these 18 patients, only five patients had delayed onset complications and four of them had at least one displaced rib fracture. In this retrospective cohort study, we found that the number of displaced or total rib fractures, bilateral rib fractures, and rib fractures in more than two areas were associated with the more chest complications. Furthermore, three or more rib fracture or any displacement were found to be the most sensitive risk factor for chest complications, independent of other risk factors or severity index. The number of displaced rib fractures could be a strong predictor for developing pulmonary complications. For patients with fewer than three rib fractures without rib displacement and initial lung or other organ injuries, outpatient management could be safe and efficient.

Blunt chest trauma in a non-specialist centre: Right treatment, right place?

PubMed

Maher, Lesley; Jayathissa, Sisira

2016-12-01

To compare patient characteristics, management and outcomes for patients admitted with isolated blunt chest trauma, managed by medical or surgical teams. We reviewed adult patients admitted with blunt chest trauma between 1 September 2006 and 31 August 2011 to a secondary hospital in New Zealand. Inclusion criteria were: blunt chest trauma, with at least one radiologically demonstrated rib fracture. The primary outcome was in-hospital mortality, and secondary outcomes were development of pneumonia, and use of analgesia. Seventy-two patients were included. Thirty-three patients were managed by medical teams and 39 by surgical teams. In-hospital mortality was greater amongst medical patients 5/33 (15%) versus surgical 0/39 (0%); P = 0.012. Pneumonia occurred in 15/33 (45%); medical patients versus surgical 2/39 (5%), P <0.001. Use of epidural, regional or patient-controlled analgesia was greater in the group managed by surgical teams (12/39 [30.7%] vs 1/33 [3%] P = 0.002). Medically managed patients were older (median 73 vs 63 years; P = 0.02), had a higher Charlson Comorbidity Index (median 5 vs 3; P = 0.013). The mechanism of injury for medically managed patients was more likely to be low trauma fall compared to surgically managed patients (28/33 [85%] vs 9/39 [27%]; P <0.0001). Amongst patients with isolated blunt chest trauma, those managed by medical teams were older, had more comorbidities and were more likely to have become injured with a low trauma fall than those managed by surgical teams. They had less access to analgesic options, developed pneumonia more often and had higher mortality. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Single-incision video-assisted thoracoscopic evaluation and emergent surgery for severe lung and chest wall injury after thoracic trauma in a water park.

PubMed

Sesma, Julio; Alvarez, Melodie; Lirio, Francisco; Galvez, Carlos; Galiana, Maria; Baschwitz, Benno; Fornes, Francisca; Bolufer, Sergio

2017-08-01

Thoracic trauma is a challenging situation with potential severe chest wall and intrathoracic organ injuries. We present a case of emergent surgery in a 23-year-old man with hemorrhagic shock due to massive lung and chest wall injury after thoracic trauma in a water slide. We performed a SI-VATS approach in order to define intrathoracic and chest wall injuries, and once checked the extension of the chest wall injury, we added a middle size thoracotomy just over the affected area in order to stabilize rib fractures with Judet plates, that had caused massive laceration in left lower lobe (LLL) and injured the pericardium causing myocardical tear. After checking bronchial and vascular viability of LLL we suggested a lung parenchyma preserving technique with PTFE protected pulmonary primary suture in order to avoid a lobectomy. Chest tubes were removed on 3 rd postoperative day and patient was discharged on 14 th postoperative day. He has already recovered his normal activity 6 months after surgery.

Single-incision video-assisted thoracoscopic evaluation and emergent surgery for severe lung and chest wall injury after thoracic trauma in a water park

PubMed Central

Alvarez, Melodie; Lirio, Francisco; Galvez, Carlos; Galiana, Maria; Baschwitz, Benno; Fornes, Francisca; Bolufer, Sergio

2017-01-01

Thoracic trauma is a challenging situation with potential severe chest wall and intrathoracic organ injuries. We present a case of emergent surgery in a 23-year-old man with hemorrhagic shock due to massive lung and chest wall injury after thoracic trauma in a water slide. We performed a SI-VATS approach in order to define intrathoracic and chest wall injuries, and once checked the extension of the chest wall injury, we added a middle size thoracotomy just over the affected area in order to stabilize rib fractures with Judet plates, that had caused massive laceration in left lower lobe (LLL) and injured the pericardium causing myocardical tear. After checking bronchial and vascular viability of LLL we suggested a lung parenchyma preserving technique with PTFE protected pulmonary primary suture in order to avoid a lobectomy. Chest tubes were removed on 3rd postoperative day and patient was discharged on 14th postoperative day. He has already recovered his normal activity 6 months after surgery. PMID:28861425

The management of bite wounds in children--a retrospective analysis at a level I trauma centre.

PubMed

Jaindl, Manuela; Grünauer, Judith; Platzer, Patrick; Endler, Georg; Thallinger, Christiane; Leitgeb, Johannes; Kovar, Florian M

2012-12-01

Animal bite wounds are a significant problem, which have caused several preventable child deaths in clinical practice in the past. The majority of bite wounds is caused by dogs and cats, and also humans have to be considered to lead to those extreme complicated diagnosis in the paediatric patient population. Early estimation of infection risk, adequate antibiotic therapy and, if indicated, surgical treatment, are cornerstones of successful cures of bite wounds. However, antibiotic prophylaxis and wound management are discussed controversially in the current literature. In our study, we retrospectively investigated the bite source, infection risk and treatment options of paediatric bite wounds. A total of 1592 paediatric trauma patients were analysed over a period of 19 years in this retrospective study at a level I trauma centre, Department of Trauma Surgery, Medical University of Vienna, Austria. Data for this study were obtained from our electronic patient records and follow-up visits. In our database, all paediatric patients triaged to our major urban trauma centre have been entered retrospectively. During the 19-year study period, 1592 paediatric trauma patients met the inclusion criteria. The mean age was 7.7 years (range 0-18.9), 878 (55.2%) were males and 714 (44.8%) were females. In our study population, a total of 698 dog bites (43.8%), 694 human bites (43.6%), 138 other bites (8.7%) and 62 cat bites (3.9%) have been observed. A total of 171 wounds (10.7%) have been infected. Surgical intervention was done in 27 wounds (1.7%). Gender-related incidence in bite wounds for dog and cat could be detected. Second, our findings for originator of bite wounds reflect the findings in the published literature. Total infection rate reached 10.7%, primary antibiotic therapy was administered in 221 cases (13.9%) and secondary antibiotic therapy in 20 (1.3%) cases. Observed infection rate of punctured wounds and wounds greater than 3 cm was 3 times higher than for all other wounds. Our findings need to be proven in further prospective clinical trials. Copyright © 2012 Elsevier Ltd. All rights reserved.

Variations in injury characteristics among paediatric patients following trauma: A retrospective descriptive analysis comparing pre-hospital and in-hospital deaths at Kamuzu Central Hospital, Lilongwe, Malawi.

PubMed

Purcell, Laura; Mabedi, Charles E; Gallaher, Jared; Mjuweni, Steven; McLean, Sean; Cairns, Bruce; Charles, Anthony

2017-06-01

Trauma is a major cause of paediatric mortality in sub-Saharan Africa. In absence of pre-hospital care, the injury mechanism and cause of death is difficult to characterise. Injury characteristics of pre-hospital deaths (PHD) versus in-hospital deaths (IHD) were compared. Using our trauma surveillance database, a retrospective, descriptive analysis of children (<18 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi from 2008 to 2013 was performed. Patient and injury characteristics of pre-hospital and in-hospital deaths were compared with univariate and bivariate analysis. Of 30,462 paediatric trauma patients presenting between 2008 and 2013, 170 and 173 were PHD and IHD, respectively. In PHD and IHD patients mean age was 7.3±4.9 v 5.2±4.3 (p<0.001), respectively. IHD patients were more likely transported via ambulance than those PHD, 51.2% v 8.3% (p<0.001). The primary mechanisms of injury for PHD were road traffic injuries (RTI) (45.8%) and drowning (22.0%), with head injury (46.7%) being the predominant cause of death. Burns were the leading mechanism of injury (61.8%) and cause of death (61.9%) in IHD, with a mean total body surface area involvement of 24.7±16.0%. RTI remains Malawi's major driver of paediatric mortality. A majority of these deaths attributed to head injury occur prior to hospitalisation; therefore the mortality burden is underestimated if accounting for IHD alone. Death in burn patients is likely due to under-resuscitation or sepsis. Improving pre-hospital care and head injury and burn management can improve injury related paediatric mortality.

Penetrating cardiac injuries in blunt chest wall trauma.

PubMed

Kanchan, Tanuj; Menezes, Ritesh G; Sirohi, Parmendra

2012-08-01

The present photocase illustrates the possible mechanism of direct cardiac injuries from broken sharp jagged fractured ends of ribs in blunt force trauma to the chest in run over traffic mishaps. We propose that the projecting fractured ends of the ribs penetrate the underlying thoracic organs due to the transient phenomenon of deformation of chest cavity under pressure in run over traffic mishaps. Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest.

PubMed

Strumwasser, Aaron; Chong, Vincent; Chu, Eveline; Victorino, Gregory P

2016-09-01

The precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). A ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. A total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. Thoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings. Copyright © 2016. Published by Elsevier Ltd.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

PubMed

Holland, Andrew J A; McBride, Craig A

2015-01-01

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Imaging of Combat-Related Thoracic Trauma - Blunt Trauma and Blast Lung Injury.

PubMed

Lichtenberger, John P; Kim, Andrew M; Fisher, Dane; Tatum, Peter S; Neubauer, Brian; Peterson, P Gabriel; Carter, Brett W

2018-03-01

Combat-related thoracic trauma (CRTT) is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries are the most common mechanisms of trauma to the chest. Imaging plays a key role in the battlefield management of CRTT casualties. This work discusses the imaging manifestations of thoracic injuries from blunt trauma and blast injury, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. The assessment of radiologic findings in patients who suffer from combat-related blunt thoracic trauma and blast injury is the basis of this work. The imaging modalities for this work include multi-detector computed tomography (MDCT) and chest radiography. Multiple imaging modalities are available to imagers on or near the battlefront, including radiography, fluoroscopy, and MDCT. MDCT with multi-planar reconstructions is the most sensitive imaging modality available in combat hospitals for the evaluation of CRTT. In modern combat, blunt and blast injuries account for a significant portion of CRTT. Individual body armor converts penetrating trauma to blunt trauma, leading to pulmonary contusion that accounted for 50.2% of thoracic injuries during OIF and OEF. Flail chest, a subset of blunt chest injury, is caused by significant blunt force to the chest and occurs four times as frequently in combat casualties when compared with the civilian population. Imaging features of CRTT have significant diagnostic and prognostic value. Pulmonary contusions on chest radiography appear as patchy consolidations in the acute setting with ill-defined and non-segmental borders. MDCT of the chest is a superior imaging modality in diagnosing and evaluating pulmonary contusion. Contusions on MDCT appear as crescentic ground-glass opacities (opacities through which lung interstitium and vasculature are still visible) and areas of consolidation that often do not respect the anatomic boundaries of the affected lobes. Additionally, small pulmonary contusions may exhibit sub-pleural sparing and may distinguish contusion from pneumonia or other lung pathology. Although pulmonary laceration is typically the result of penetrating trauma, laceration may also be caused by displaced rib fractures or significant shearing forces on the lung without penetrating injury. Because of elastic recoil of the normal pulmonary parenchyma surrounding the injury, pulmonary lacerations may present as late as 48-72 h after injury. Pulmonary lacerations may appear similar to pulmonary contusions on chest radiography initially and will require MDCT for definitive diagnosis. Blast injury is a defining injury of modern combat. Blast lung injury is initially diagnosed with chest radiography, where the pattern of lung opacities has previously been described by clinicians as "batwing" or "butterfly" because of its central appearance in the lung. "Peribronchovascular" may be a more accurate description of primary blast lung based on its appearance on MDCT. This pattern may differentiate primary blast lung injury from other causes of thoracic trauma. CRTT continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. The distinct injury patterns and atypical imaging manifestations of blunt trauma and blast lung injury are important to recognize early because of the acuity of this patient population and the influence of accurate diagnosis on clinical management.

Chest MR imaging in the follow-up of pulmonary alterations in paediatric patients with middle lobe syndrome: comparison with chest X-ray.

PubMed

Fraioli, F; Serra, G; Ciarlo, G; Massaccesi, V; Liberali, S; Fiorelli, A; Macrì, F; Catalano, C

2013-04-01

The authors evaluated the role of magnetic resonance (MR) imaging of the chest in comparison with chest X-ray in the follow-up of pulmonary abnormalities detected by computed tomography (CT) in paediatric patients with middle lobe syndrome. Seventeen patients with middle lobe syndrome (mean age 6.2 years) underwent chest CT at the time of diagnosis (100 kV, CARE dose with quality reference of 70 mAs; collimation 24×1.2 mm; rotation time 0.33 s; scan time 5 s); at follow-up after a mean of 15.3 months, all patients were evaluated with chest MR imaging with a respiratory-triggered T2-weighted BLADE sequence (TR 2,000; TE 27 ms; FOV 400 mm; flip angle 150°; slice thickness 5 mm) and chest X-ray. Images from each modality were assessed for the presence of pulmonary consolidations, bronchiectases, bronchial wall thickening and mucous plugging. Hilar and mediastinal lymphadenopathies were assessed on CT and MR images. Baseline CT detected consolidations in 100% of patients, bronchiectases in 35%, bronchial wall thickening in 53% and mucous plugging in 35%. MR imaging and chest X-ray identified consolidations in 65% and 35%, bronchiectases in 35% and 29%, bronchial wall thickening in 59% and 6% and mucous plugging in 25% and 0%, respectively. Lymphadenopathy was seen in 64% of patients at CT and in 47% at MR imaging. Patients with middle lobe syndrome show a wide range of parenchymal and bronchial abnormalities at diagnosis. Compared with MR imaging, chest X-ray seems to underestimate these changes. Chest MR imaging might represent a feasible and radiation-free option for an overall assessment of the lung in the follow-up of patients with middle lobe syndrome.

Does hemopericardium after chest trauma mandate sternotomy?

PubMed

Thorson, Chad M; Namias, Nicholas; Van Haren, Robert M; Guarch, Gerardo A; Ginzburg, Enrique; Salerno, Tomas A; Schulman, Carl I; Livingstone, Alan S; Proctor, Kenneth G

2012-06-01

Recently, three patients with hemopericardium after severe chest trauma were successfully managed nonoperatively at our institution. This prompted the question whether these were rare or common events. Therefore, we reviewed our experience with similar injuries to test the hypothesis that trauma-induced hemopericardium mandates sternotomy. Records were retrospectively reviewed for all patients at a Level I trauma center (December 1996 to November 2011) who sustained chest trauma with pericardial window (PCW, n = 377) and/or median sternotomy (n = 110). Fifty-five (15%) patients with positive PCW proceeded to sternotomy. Penetrating injury was the dominant mechanism (n = 49, 89%). Nineteen (35%) were hypotensive on arrival or during initial resuscitation. Most received surgeon-performed focused cardiac ultrasound examinations (n = 43, 78%) with positive results (n = 25, 58%). Ventricular injuries were most common, with equivalent numbers occurring on the right (n = 16, 29%) and left (n = 15, 27%). Six (11%) with positive PCW had isolated pericardial lacerations, but 21 (38%) had no repairable cardiac or great vessel injury. Those with therapeutic versus nontherapeutic sternotomies were similar with respect to age, mechanisms of injury, injury severity scores, presenting laboratory values, resuscitation fluids, and vital signs. Multiple logistic regression revealed that penetrating trauma (odds ratio: 13.3) and hemodynamic instability (odds ratio: 7.8) were independent predictors of therapeutic sternotomy. Hemopericardium per se may be overly sensitive for diagnosing cardiac or great vessel injuries after chest trauma. Some stable blunt or penetrating trauma patients without continuing intrapericardial bleeding had nontherapeutic sternotomies, suggesting that this intervention could be avoided in selected cases. Therapeutic study, level III. Copyright © 2012 by Lippincott Williams & Wilkins.

Optimisation and establishment of diagnostic reference levels in paediatric plain radiography

NASA Astrophysics Data System (ADS)

Paulo, Graciano do Nascimento Nobre

Purpose: This study aimed to propose Diagnostic Reference Levels (DRLs) in paediatric plain radiography and to optimise the most frequent paediatric plain radiography examinations in Portugal following an analysis and evaluation of current practice. Methods and materials: Anthropometric data (weight, patient height and thickness of the irradiated anatomy) was collected from 9,935 patients referred for a radiography procedure to one of the three dedicated paediatric hospitals in Portugal. National DRLs were calculated for the three most frequent X-ray procedures at the three hospitals: chest AP/PA projection; abdomen AP projection; pelvis AP projection. Exposure factors and patient dose were collected prospectively at the clinical sites. In order to analyse the relationship between exposure factors, the use of technical features and dose, experimental tests were made using two anthropomorphic phantoms: a) CIRSTM ATOM model 705; height: 110cm, weight: 19kg and b) Kyoto kagakuTM model PBU-60; height: 165cm, weight: 50kg. After phantom data collection, an objective image analysis was performed by analysing the variation of the mean value of the standard deviation, measured with OsiriX software (Pixmeo, Switzerland). After proposing new exposure criteria, a Visual Grading Characteristic image quality evaluation was performed blindly by four paediatric radiologists, each with a minimum of 10 years of professional experience, using anatomical criteria scoring. Results: DRLs by patient weight groups have been established for the first time. ESAKP75 DRLs for both patient age and weight groups were also obtained and are described in the thesis. Significant dose reduction was achieved through the implementation of an optimisation programme: an average reduction of 41% and 18% on KAPP75 and ESAKP75, respectively for chest plain radiography; an average reduction of 58% and 53% on KAPP75 and ESAKP75, respectively for abdomen plain radiography; and an average reduction of 47% and 48% on KAPP75 and ESAKP75, respectively for pelvis plain radiography. Conclusion: Portuguese DRLs for plain radiography were obtained for paediatric plain radiography (chest AP/PA, abdomen and pelvis). Experimental phantom tests identified adequate plain radiography exposure criteria, validated by objective and subjective image quality analysis. The new exposure criteria were put into practice in one of the paediatric hospitals, by introducing an optimisation programme. The implementation of the optimisation programme allowed a significant dose reduction to paediatric patients, without compromising image quality. (Abstract shortened by ProQuest.).

Blunt Criterion trauma model for head and chest injury risk assessment of cal. 380 R and cal. 22 long blank cartridge actuated gundog retrieval devices.

PubMed

Frank, Matthias; Bockholdt, Britta; Peters, Dieter; Lange, Joern; Grossjohann, Rico; Ekkernkamp, Axel; Hinz, Peter

2011-05-20

Blunt ballistic impact trauma is a current research topic due to the widespread use of kinetic energy munitions in law enforcement. In the civilian setting, an automatic dummy launcher has recently been identified as source of blunt impact trauma. However, there is no data on the injury risk of conventional dummy launchers. It is the aim of this investigation to predict potential impact injury to the human head and chest on the basis of the Blunt Criterion which is an energy based blunt trauma model to assess vulnerability to blunt weapons, projectile impacts, and behind-armor-exposures. Based on experimentally investigated kinetic parameters, the injury risk of two commercially available gundog retrieval devices (Waidwerk Telebock, Germany; Turner Richards, United Kingdom) was assessed using the Blunt Criterion trauma model for blunt ballistic impact trauma to the head and chest. Assessing chest impact, the Blunt Criterion values for both shooting devices were higher than the critical Blunt Criterion value of 0.37, which represents a 50% risk of sustaining a thoracic skeletal injury of AIS 2 (moderate injury) or AIS 3 (serious injury). The maximum Blunt Criterion value (1.106) was higher than the Blunt Criterion value corresponding to AIS 4 (severe injury). With regard to the impact injury risk to the head, both devices surpass by far the critical Blunt Criterion value of 1.61, which represents a 50% risk of skull fracture. Highest Blunt Criterion values were measured for the Turner Richards Launcher (2.884) corresponding to a risk of skull fracture of higher than 80%. Even though the classification as non-guns by legal authorities might implicate harmlessness, the Blunt Criterion trauma model illustrates the hazardous potential of these shooting devices. The Blunt Criterion trauma model links the laboratory findings to the impact injury patterns of the head and chest that might be expected. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Selective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm).

PubMed

Rodriguez, Robert M; Hendey, Gregory W; Mower, William R

2017-01-01

Chest imaging plays a prominent role in blunt trauma patient evaluation, but indiscriminate imaging is expensive, may delay care, and unnecessarily exposes patients to potentially harmful ionizing radiation. To improve diagnostic chest imaging utilization, we conducted 3 prospective multicenter studies over 12years to derive and validate decision instruments (DIs) to guide the use of chest x-ray (CXR) and chest computed tomography (CT). The first DI, NEXUS Chest x-ray, consists of seven criteria (Age >60years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and exhibits a sensitivity of 99.0% (95% confidence interval [CI] 98.2-99.4%) and a specificity of 13.3% (95% CI, 12.6%-14.0%) for detecting clinically significant injuries. We developed two NEXUS Chest CT DIs, which are both highly reliable in detecting clinically major injuries (sensitivity of 99.2%; 95% CI 95.4-100%). Designed primarily to focus on detecting major injuries, the NEXUS Chest CT-Major DI consists of six criteria (abnormal CXR; distracting injury; chest wall tenderness; sternal tenderness; thoracic spine tenderness; and scapular tenderness) and exhibits higher specificity (37.9%; 95% CI 35.8-40.1%). Designed to reliability detect both major and minor injuries (sensitivity 95.4%; 95% CI 93.6-96.9%) with resulting lower specificity (25.5%; 95% CI 23.5-27.5%), the NEXUS CT-All rule consists of seven elements (the six NEXUS CT-Major criteria plus rapid deceleration mechanism). The purpose of this review is to synthesize the three DIs into a novel, cohesive summary algorithm with practical implementation recommendations to guide selective chest imaging in adult blunt trauma patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Tricuspid regurgitation due to chest trauma: an unusual laceration around the annulus of the anterior leaflet.

PubMed

Ishii, K; Koga, Y; Maeda, M; Nakamura, K; Sekiya, R; Yonezawa, T; Onitsuka, T; Shibata, K

1988-01-01

A 70-year-old male with tricuspid regurgitation due to a blunt chest trauma inflicted 16 years previously underwent prosthetic valve replacement. At surgery, a tear, which produced tricuspid regurgitation, was found around the annulus of the anterior leaflet of the tricuspid valve. Since this area has not been reported as a location for heart trauma-producing tricuspid regurgitation, a possible mechanism of tricuspid regurgitation is discussed in this patient.

[Indicators of severity in chest trauma].

PubMed

Freixinet, Jordi; Beltrán, Juan; Rodríguez, Pedro Miguel; Juliá, Gabriel; Hussein, Mohammed; Gil, Rita; Herrero, Jorge

2008-05-01

We undertook a review of patients with chest trauma attended between January 1992 and June 2005 in order to establish severity criteria in these cases. During the study period, 1,772 cases (1,346 [76%] males) were treated, with ages ranging from 7 to 98 years (mean, 46.4 years). The Revised Trauma Score (RTS) was calculated and the following variables were also studied as potential indicators of severity: age, extent of the injury, number of rib fractures, presence of lung contusion, hemothorax, cardiorespiratory repercussions, and need for mechanical ventilation. At the time of admission, 84.4% of patients presented only symptoms related to the injury, with no general repercussions, and 66.7% had an RTS of 12. The number of rib fractures was a reliable indicator of severity, as was the presence of multiple injuries, lung contusion, need for mechanical ventilation, and cardiorespiratory repercussions. Neither age nor presence of hemothorax was found to be an indicator of severity. Pleural drainage was performed in 756 cases and was effective in 670 (88.6%). There are a number of indicators of severity in chest trauma, related more closely to the type and repercussions of the trauma than to the age of the patient. There is a high incidence of fluid or gas accumulation in the pleural space, though this can be easily managed by pleural drainage, which constitutes the main therapeutic procedure in chest trauma.

A study on the evaluation of pneumothorax by imaging methods in patients presenting to the emergency department for blunt thoracic trauma.

PubMed

Kaya, Şeyhmus; Çevik, Arif Alper; Acar, Nurdan; Döner, Egemen; Sivrikoz, Cumhur; Özkan, Ragıp

2015-09-01

Pneumothorax (PNX) is the collection of air between parietal and visceral pleura, and collapsed lung develops as a complication of the trapped air. PNX is likely to develop spontaneously in people with risk factors. However, it is mostly seen with blunt or penetrating trauma. Diagnosis is generally confirmed by chest radiography [posteroanterior chest radiography (PACR)]. Chest ultrasound (US) is also a promising technique for the detection of PNX in trauma patients. There is not much literature on the evaluation of blunt thoracic trauma (BTT) and pneumothorax (PNX) in the emergency department (ED). The aim of this study was to investigate the effectiveness of chest US for the diagnosis of PNX in patients presenting to ED with BTT. This study was carried out for a period of nine months in the ED of a university hospital. The chest US of patients was performed by emergency physicians trained in the field. The results were compared with anteroposterior chest radiography and/or CT scan of the chest. The APCR and chest CT results were evaluated by a radiology specialist blind to US findings. The evaluation of the radiology specialist was taken as the gold standard for diagnosis by imaging methods. Clinical follow-up was taken into consideration for the diagnosis of PNX in patients on whom CT scan was not performed. Chest US was performed on all two hundred and twelve patients (144 female and 68 male patients; mean age 45.8) who participated in this study. The supine APCR was performed on two hundred and ten (99%) patients and chest CT was performed on one hundred and twenty (56.6%). Out of the twenty-five (11.8%) diagnosed cases of PNX, 22 (88%) were diagnosed by chest US and 8 were diagnosed by APCR. For the detection of PNX, compared to clinical follow-up and chest CT, the sensitivity of chest US was 88%, specificity 99.5%, positive predictive value 95.7% and negative predictive value 98.4%. Chest US has not superseded supine and standing chest radiography for PNX diagnosis yet in many healthcare centers, but it is performed by emergency physicians and it is an effective and important method for early and bedside diagnosis of PNX.

A review of blood transfusions in a trauma unit for young children.

PubMed

Salverda, M; Ketharanathan, N; Van Dijk, M; Beltchev, E; Buys, H; Numanoglu, A; Van As, A B

2017-02-27

Trauma is the leading cause of mortality and morbidity worldwide. Blood transfusions play an incremental role in the acute phase, yet practice varies owing to variations in transfusion thresholds and concerns about potential complications, especially in children. To evaluate protocol adherence to blood transfusion thresholds in paediatric trauma patients and determine the degree of blood product wastage, as defined by discarded units. A retrospective, descriptive study of trauma patients (age 0 - 13 years) who received a blood transfusion in the trauma unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, over a 5.5-year period (1 January 2009 - 1 July 2014). Haemoglobin (Hb) transfusion thresholds were defined as 10 g/dL for neurotrauma patients and patients requiring skin grafting or a musculocutaneous flap (group 1). All other trauma patients had an Hb transfusion threshold of 7 g/dL (group 2). A total of 144 patients were included (mean age 5.2 years (standard deviation (SD) 3.3), 68.1% male). The mean Hb increase after transfusion was 3.5 g/dL (SD 1.7). Adherence to the transfusion Hb threshold protocol was 96.7% for group 1 v. 34.0% for group 2. No complications were reported. Average blood wastage was 3.5 units per year during the study period. Adherence to paediatric blood transfusion protocol was low in the Hb threshold group <7 g/dL. However, transfusion-related complications and wastage were minimal. Further prospective research is required to determine optimal blood transfusion guidelines for paediatric trauma patients.

Paediatric pancreatic trauma: a review of the literature and results of a multicentre survey on patient management.

PubMed

Westgarth-Taylor, C; Loveland, J

2014-11-01

It is generally accepted that paediatric solid organ injury should be treated conservatively, unless there is haemodynamic instability unresponsive to resuscitation. When it comes to pancreatic trauma, there is much debate about appropriate management. To review the literature and determine how pancreatic trauma is managed in South African (SA) tertiary institutions and compares with international standards. A survey was emailed to 45 paediatric surgical consultants working in various paediatric surgical units in SA, Italy, England and Australia. The questionnaire comprised two scenarios of isolated pancreatic trauma (grade III), the main difference between them being the time interval between initial injury and presentation. In the first scenario, the patient presented 6 hours post injury whereas in the second scenario, the patient presented 6 days post initial injury. The survey enquired about diagnosis and subsequent work-up (including preferred imaging techniques), supportive management (including nutrition), the various options of definitive intervention and follow-up procedure. There were 21 responders from four different countries. In the first scenario, 10 surgeons would operate, 8 would treat conservatively and 3 would perform an endoscopic retrograde cholangiopancreatogram (ERCP) and stent. In. the second scenario, 4 surgeons would operate, 13 would treat conservatively and 4 would undertake ERCP with stent. There was no difference in management between the SA surgeons and their international counterparts. Management of blunt pancreatic trauma in SA is consistent with that reported in the literature. There is still controversy regarding the optimal management of pancreatic injury involving ducts. No absolute algorithm can be used to treat these patients. All patients should be treated individually and managed with an approach and techniques that are feasible.

Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma

PubMed Central

Chou, Yi-Pin; Lin, Hsing-Lin; Wu, Tzu-Chin

2015-01-01

Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively. PMID:25978625

Cardio-embolic stroke following remote blunt chest trauma.

PubMed

Arora, Sonali; Atreya, Auras R; Penumetsa, Srikanth C; Hiser, William L

2013-03-01

A cardio-embolic stroke as a sequela of remote blunt chest trauma is a rare clinical presentation. Blunt chest trauma can cause various acute cardiac complications like arrhythmias, cardiac contusion etc. However, delayed consequences such as left ventricular thrombus resulting in thromboembolic phenomena are reported infrequently. A 30-year-old healthy man presented to an outside facility with transient neurological deficits. An MRI brain showed lesions suggestive of embolic etiology. A trans-thoracic echocardiogram (TTE) showed a 1.5 × 1.5 cm mass present in the left ventricular (LV) apex. Patient was transferred to our institution for cardiac surgery evaluation. On detailed questioning, he reported an incident of blunt chest trauma during a martial arts exhibition fight that took place 2 years back. Given this history, a cardiac catheterization was done, which showed 30% stenosis in mid-left anterior descending artery (LAD) without any other significant obstructive lesion. A trans-esophageal echocardiogram (TEE) showed akinesis of the LV apex and confirmed TTE finding of a mass, consistent with an apical thrombus. Surgery was deferred and patient was started on anticoagulation. A cardiac MRI done 2 weeks later showed evidence of apical infarction in the LAD territory. LAD is the most commonly affected coronary vessel by blunt traumatic injuries, likely due to its vulnerable anatomical position on the anterior aspect of the heart. A variety of mechanisms including intimal tear, rupture and spasm have been implicated in the pathogenesis of myocardial infarction after blunt chest trauma.

Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02.

PubMed

Butler, Frank K; Dubose, Joseph J; Otten, Edward J; Bennett, Donald R; Gerhardt, Robert T; Kheirabadi, Bijan S; Gross, Kriby R; Cap, Andrew P; Littlejohn, Lanny F; Edgar, Erin P; Shackelford, Stacy A; Blackbourne, Lorne H; Kotwal, Russ S; Holcomb, John B; Bailey, Jeffrey A

2013-01-01

During the recent United States Central Command (USCENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: ?All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vente chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.? This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013. 2013.

Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures.

PubMed

Chapman, Brandon C; Overbey, Douglas M; Tesfalidet, Feven; Schramm, Kristofer; Stovall, Robert T; French, Andrew; Johnson, Jeffrey L; Burlew, Clay C; Barnett, Carlton; Moore, Ernest E; Pieracci, Fredric M

2016-12-01

Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student's t-test and chi-square analysis were used for comparison. We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

The floating cardiac fat pad-sign of occult pneumothorax.

PubMed

Kaufman, Claire; Bokhari, S A Jamal

2016-08-01

Pneumothoraces are a possible sequela of chest trauma with potential morbidity and mortality if not recognized and treated promptly. A portable supine chest radiograph is frequently the first radiologic study performed in the setting of trauma. While large pneumothoraces can be readily recognized on these radiographs, smaller pneumothoraces are missed in up to 15 % of trauma patients. There are many radiographic signs of occult pneumothoraces, and we are presenting a new radiographic sign of occult pneumothorax. The floating cardiac fat pad sign occurs when pleural air collects anteriorly and superiorly in the most non-dependent portion of the chest lifting the pericardial fat pad off the diaphragm. Lung markings are still seen surrounding the pericardial fat pad due to the inflated lower lobe of the lung resting dependently. Rapid and accurate identification of pneumothoraces is critical but often difficult on chest radiographs. Although there are many existing radiographic signs for identification of pneumothorax, prospective identification of small pneumothoraces is still relatively poor. Here, we describe an additional sign which aides in the detection of pneumothoraces, the floating cardiac fat pad. When present, this should prompt further evaluation with chest CT or upright chest radiograph.

Myocardial contusion in patients with blunt chest trauma as evaluated by thallium 201 myocardial scintigraphy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bodin, L.; Rouby, J.J.; Viars, P.

1988-07-01

Fifty five patients suffering from blunt chest trauma were studied to assess the diagnosis of myocardial contusion using thallium 201 myocardial scintigraphy. Thirty-eight patients had consistent scintigraphic defects and were considered to have a myocardial contusion. All patients with scintigraphic defects had paroxysmal arrhythmias and/or ECG abnormalities. Of 38 patients, 32 had localized ST-T segment abnormalities; 29, ST-T segment abnormalities suggesting involvement of the same cardiac area as scintigraphic defects; 21, echocardiographic abnormalities. Sixteen patients had segmental hypokinesia involving the same cardiac area as the scintigraphic defects. Fifteen patients had clinical signs suggestive of myocardial contusion and scintigraphic defects. Almostmore » 70 percent of patients with blunt chest trauma had scintigraphic defects related to areas of myocardial contusion. When thallium 201 myocardial scintigraphy directly showed myocardial lesion, two-dimensional echocardiography and standard ECG detected related functional consequences of cardiac trauma.« less

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury.

PubMed

Hershkovitz, Yehuda; Zoarets, Itai; Stepansky, Albert; Kozer, Eran; Shapira, Zahar; Klin, Baruch; Halevy, Ariel; Jeroukhimov, Igor

2014-07-01

Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury. Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation. Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention. The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified. Copyright © 2014 Elsevier Inc. All rights reserved.

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®)

PubMed Central

2014-01-01

Background Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality. Methods All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002–2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed. Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma. Results 22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days). Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality. Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval. Conclusions We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma. PMID:25204466

Delayed pneumothorax complicating minor rib fracture after chest trauma.

PubMed

Lu, Ming-Shian; Huang, Yao-Kuang; Liu, Yun-Hen; Liu, Hui-Ping; Kao, Chiung-Lun

2008-06-01

Pneumothorax (PTX) after trauma is a preventable cause of death. Drainage procedures such as chest tube insertion have been traditionally advocated to prevent fatal tension PTX. We evaluated the safety of close observation in patients with delayed PTX complicating rib fracture after minor chest trauma. Adult patients (>18 years) with a diagnosis of chest trauma and 3 or fewer fractured ribs were reviewed. Case patients were divided according to age, location and number of fractured ribs, mechanism of trauma, and initial pulmonary complication after thoracic trauma for comparative analysis. There were 207 male (70.2%) and 88 female (29.8%) patients whose ages ranged from 18 to 93 years (median, 55 years). The mechanisms of trauma were a motor vehicle accident in 207 patients, falls in 66, pedestrian injury in 10, and assaults in 14. Ninety-five patients sustained 1 rib fracture, 95 had 2 rib fractures, and 105 suffered 3 rib fractures. Right-sided injury occurred in 164 cases, left-sided injury did in 127, and bilateral injury did in 4. The most frequent location of rib fractures was from the fourth rib to the ninth rib. The initial pulmonary complications after trauma were PTX in 16 patients, hemothorax in 43, pneumohemothorax in 14, lung contusion in 75, and isolated subcutaneous emphysema (SubcEmph) in 33. Thirty percent of the patients (n = 5/16) who presented with traumatic PTX were observed safely without drainage. Delayed PTX was recorded in 16 patients, occurring mostly during the first 2 days of their admission. Associated extrathoracic injury was recorded in 189 patients. The mean hospital stay of the patients was 7.66 days. Longer hospital stay was related to increasing number of fractured ribs, need for thoracic drainage, and the presence of associated extrathoracic injury. The mortality rate for the entire group was 2%. The presence of SubcEmph was the only risk factor associated with the development of delayed PTX. Patients sustaining blunt chest trauma and minor rib fractures should be admitted for close observation when presenting with SubcEmph because of possible delayed presentation of PTX.

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®).

PubMed

Huber, Stephan; Biberthaler, Peter; Delhey, Patrick; Trentzsch, Heiko; Winter, Hauke; van Griensven, Martijn; Lefering, Rolf; Huber-Wagner, Stefan

2014-09-03

Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality. All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002-2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed. Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma. 22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days). Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality. Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval. We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma.

Thoracic Trauma.

PubMed

Dennis, Bradley M; Bellister, Seth A; Guillamondegui, Oscar D

2017-10-01

Management of chest trauma is integral to patient outcomes owing to the vital structures held within the thoracic cavity. Understanding traumatic chest injuries and appropriate management plays a pivotal role in the overall well-being of both blunt and penetrating trauma patients. Whether the injury includes rib fractures, associated pulmonary injuries, or tracheobronchial tree injuries, every facet of management may impact the short- and long-term outcomes, including mortality. This article elucidates the workup and management of the thoracic cage, pulmonary and tracheobronchial injuries. Copyright © 2017 Elsevier Inc. All rights reserved.

Selective common and uncommon imaging manifestations of blunt nonaortic chest trauma: when time is of the essence.

PubMed

Altoos, Rola; Carr, Robert; Chung, Jonathan; Stern, Eric; Nevrekar, Dipti

2015-01-01

This is a pictorial essay in which we review and illustrate a variety of thoracic injuries related to blunt trauma. Non-aortic blunt thoracic trauma can be divided anatomically into injuries of the chest wall, lungs, pleura, mediastinum, and diaphragm. Some injuries involve more than one anatomic compartment, and multiple injuries commonly coexist. This article provides common imaging findings and discussion of both common and uncommon but critical thoracic injuries encountered. Published by Elsevier Inc.

Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan.

PubMed

Suzuki, Kodai; Inoue, Shigeaki; Morita, Seiji; Watanabe, Nobuo; Shintani, Ayumi; Inokuchi, Sadaki; Ogura, Shinji

2016-01-01

Although emergency resuscitative thoracotomy is performed as a salvage maneuver for critical blunt trauma patients, evidence supporting superior effectiveness of emergency resuscitative thoracotomy compared to conventional closed-chest compressions remains insufficient. The objective of this study was to investigate whether emergency resuscitative thoracotomy at the emergency department or in the operating room was associated with favourable outcomes after blunt trauma and to compare its effectiveness with that of closed-chest compressions. This was a retrospective nationwide cohort study. Data were obtained from the Japan Trauma Data Bank for the period between 2004 and 2012. The primary and secondary outcomes were patient survival rates 24 h and 28 d after emergency department arrival. Statistical analyses were performed using multivariable generalized mixed-effects regression analysis. We adjusted for the effects of different hospitals by introducing random intercepts in regression analysis to account for the differential quality of emergency resuscitative thoracotomy at hospitals where patients in cardiac arrest were treated. Sensitivity analyses were performed using propensity score matching. In total, 1,377 consecutive, critical blunt trauma patients who received cardiopulmonary resuscitation in the emergency department or operating room were included in the study. Of these patients, 484 (35.1%) underwent emergency resuscitative thoracotomy and 893 (64.9%) received closed-chest compressions. Compared to closed-chest compressions, emergency resuscitative thoracotomy was associated with lower survival rate 24 h after emergency department arrival (4.5% vs. 17.5%, respectively, P < 0.001) and 28 d after arrival (1.2% vs. 6.0%, respectively, P < 0.001). Multivariable generalized mixed-effects regression analysis with and without a propensity score-matched dataset revealed that the odds ratio for an unfavorable survival rate after 24 h was lower for emergency resuscitative thoracotomy than for closed-chest compressions (P < 0.001). Emergency resuscitative thoracotomy was independently associated with decreased odds of a favorable survival rate compared to closed-chest compressions.

Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm?

PubMed

Abdulrahman, Yassir; Musthafa, Shameel; Hakim, Suhail Y; Nabir, Syed; Qanbar, Ahad; Mahmood, Ismail; Siddiqui, Tariq; Hussein, Wafaa A; Ali, Hazim H; Afifi, Ibrahim; El-Menyar, Ayman; Al-Thani, Hassan

2015-01-01

The clinical significance of extended Focused Assessment with Sonography for Trauma (EFAST) for diagnosis of pneumothorax is not well defined. To investigate the utility of EFAST in blunt chest trauma (BCT) patients. A single blinded, prospective study. All patients admitted with BCT (2011-2013). Level 1 trauma center in Qatar. Patients were screened by EFAST and results were compared to the clinical examination (CE) and chest X-ray (CXR). Chest-computed tomography (CT) scoring system was used to confirm and measure the pneumothorax. Diagnostic accuracy of diagnostic modalities of pneumothorax was measured using sensitivity, specificity, predictive values (PVs), and likelihood ratio. A total of 305 BCT patients were included with median age of 34 (18-75). Chest CT was positive for pneumothorax in 75 (24.6 %) cases; of which 11 % had bilateral pneumothorax. Chest CT confirmed the diagnosis of pneumothorax in 43, 41, and 11 % of those who were initially diagnosed by EFAST, CE, and CXR, respectively. EFAST was positive in 42 hemithoraces and its sensitivity (43 %) was higher in comparison to CXR (11 %). Positive and negative PVs of EFAST were 76 and 92 %, respectively. The frequency of missed cases by CXR was higher in comparison to EFAST and CE. The lowest median score of missed pneumothorax was observed by EFAST. EFAST can be used as an efficient triaging tool in BCT patients to rule out pneumothorax. Based on our analysis, we would recommend EFAST as an adjunct in ATLS algorithm.

Myocardial contusion following nonfatal blunt chest trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kumar, S.A.; Puri, V.K.; Mittal, V.K.

1983-04-01

Currently available diagnostic techniques for myocardial contusion following blunt chest trauma were evaluated. We investigated 30 patients prospectively over a period of 1 year for the presence of myocardial contusion. Among the 30 patients, eight were found to have myocardial contusion on the basis of abnormal electrocardiograms, elevated creatine phosphokinase MB fraction (CPK-MB), and positive myocardial scan. Myocardial scan was positive in seven of eight patients (87.5%). CPK-MB fraction was elevated in four of eight patients (50%). Definitive electrocardiographic changes were seen in only two of eight patients (25%). It appears that myocardial scan using technetium pyrophosphate and CPK-MB fractionmore » determinations are the most reliable aids in diagnosis of myocardial contusion following blunt chest trauma.« less

Using micropower impulse radar technology to screen for pneumothorax: an international bi-institutional study.

PubMed

van der Wilden, Gwendolyn M; Van der Wilden, Gwen; Albers, Christoph E; Albers, Christof; Haefeli, Pascal C; Haefeli, Peter; Zimmermann, Heinz; Zimmerman, Heinz; Exadaktylos, Aristomenis; Exadaktylos, Aris; Levy, Phillip; Birkhan, Oscar; Birkham, Oscar; Michaildou, Maria; Michailidou, Maria; Sideris, Antonios; Velmahos, George C; Velmahos, George; Alam, Hasan B; Alam, Hasan; King, David R; King, David; Fagenholz, Peter J; Fagenholz, Peter; Yeh, D Dante; Yeh, Dante; de Moya, Marc A

2012-12-01

Pneumothoraces (PTXs) are a common entity in thoracic trauma. Micropower impulse radar (MIR) has been able to detect PTXs in surgical patients. However, this technology has not been tested previously on trauma patients. The purpose of this study was to determine the sensitivity and specificity of MIR to detect clinically significant PTXs. We hypothesized that MIR technology can effectively screen trauma patients for clinically significant PTXs. This was a prospective observational study in Level I trauma centers in Boston, Massachusetts, and Bern, Switzerland. All trauma patients undergoing a chest computed tomographic (CT) scan were eligible for the study. Consent was obtained, and readings were performed within 30 minutes before or after the CT scan. The patients had eight lung fields tested (four on each side). The qualitative and quantitative MIR results were blinded and stored on the device. We then compared the results of the MIR to the CT scan and the need for chest tube drainage. We defined PTXs as clinically significant if they required a chest tube. Seventy-five patients were enrolled, with a mean age of 46 ± 16 years. Eighty-four percent were male. The screening test took approximately 1 minute. All but two patients had blunt chest trauma. Six true-positives, 6 false-positives, 63 true-negatives, and 0 false-negatives resulted in an overall sensitivity of 100%. MIR is an easy to use handheld technology that effectively screened patients for clinically significant PTXs, with a sensitivity and negative predictive value of 100%. MIR may be used for rapid, repeatable, and ongoing surveillance of trauma patients. Diagnostic study, level III.

EVALUATION OF THORACOSCOPY IN THE DIAGNOSIS OF DIAPHRAGMATIC INJURIES IN PENETRATING THORACOABDOMINAL TRAUMA WITHOUT LUNG DEFLATION AT DR GEORGE MUKHARI ACADEMIC HOSPITAL.

PubMed

Nsakala, L

2017-06-01

With a mortality estimated at 25% when missed, diaphragmatic injuries due to penetrating thoracoabdominal trauma present a diagnostic challenge for both the radiologist and the surgeon. In the current literature, chest x-ray has a sensitivity of 27-60% for left-sided injuries and only 17% for right-sided injuries while, CT scan has a sensitivity of 14-61% and a specificity of 76-99%. Thoracoscopy using a single lung ventilation is one of the modalities of choice for the diagnosis of these injuries with a specificity of 100% and a sensitivity of 87.5%. This was a prospective study; all stable trauma patients with penetrating thoracoabdominal injury aged 18 years and above admitted to the trauma unit at Dr George Mukhari Academic Hospital during the period of the study were included. All patients with penetrating thoracoabdominal trauma who were unstable, or necessitating prompt management and all paediatric patients were excluded from the study. In theatre, under general anaesthesia, we first performed thoracoscopy without single lung ventilation followed by laparoscopy as control on each patient. Data was collected using a standard proforma by the attending surgeon and was analysed by a statistician using IBM SPSS 22 software. A total of 32 patients met the inclusion criteria of which 4 were female (12.5%) and 28 male (87.5%) with the median age of 29 years. Of the 32 patients, 27 had thoracoabdominal stab wounds (84.3%) and 5 had gunshot wounds (15.6%). Fourteen patients (43.75%) had left sided injury and 18 patients (56.25%) had injury to the right side. The incidence of diaphragmatic injury was 37.5% (n = 12). No injuries were missed on thoracoscopy; there was no mortality or morbidity. Thoracoscopy without single lung ventilation is safe and comparable to thoracoscopy with single lung ventilation as a diagnostic tool for diaphragmatic injuries in stable patients with penetrating thoracoabdominal trauma.

Rethinking Traditional Behaviour Management to Better Support Complex Trauma-Surviving Students

ERIC Educational Resources Information Center

Howard, Judith

2016-01-01

Children and adolescents who have survived complex trauma have suffered the type of ongoing and repeated traumatic experience that includes factors such as physical, sexual, and/or emotional abuse, significant neglect, and/or family violence. Complex childhood trauma (sometimes referred to as paediatric or child maltreatment-related post traumatic…

Management of paediatric liver trauma.

PubMed

van As, A B; Millar, Alastair J W

2017-04-01

Of all the intra-abdominal solid organs, the liver is the most vulnerable to blunt abdominal trauma. The majority of liver ruptures present in combination with other abdominal or extra-abdominal injuries. Over the last three decades, the management of blunt liver trauma has evolved from obligatory operative to non-operative management in over 90% of cases. Penetrating liver injuries more often require operative intervention and are managed according to adult protocols. The greatest clinical challenge remains the timely identification of the severely damaged liver with immediate and aggressive resuscitation and expedition to laparotomy. The operative management can be taxing and should ideally be performed in a dedicated paediatric surgical centre with experience in dealing with such trauma. Complications can occur early or late and include haemobilia, intrahepatic duct rupture with persistent biliary fistula, bilaemia, intrahepatic haematoma, post-traumatic cysts, vascular outflow obstruction, and gallstones. The prognosis is generally excellent.

Traumatic pulmonary pseudocysts after blunt chest trauma: Prevalence, mechanisms of injury, and computed tomography findings.

PubMed

Cho, Hyun Jin; Jeon, Yang Bin; Ma, Dae Sung; Lee, Jung Nam; Chung, Min

2015-09-01

Traumatic pulmonary pseudocyst (TPP) is a rare complication of blunt chest trauma and closely related with severe injury. However, it has been poorly documented. We present a retrospective review of TPP cases treated at our hospital. The medical records and chest computed tomography scans of patients with TPP treated from January 2010 to December 2013 were retrospectively studied. A total of 978 patients underwent chest computed tomography for blunt chest trauma during the study period, and 81 (8.3%) had a total of 150 TPPs. The most common mechanism of injury was being struck by a motorized vehicle (n = 25, 30.9%). The mean (SD) Injury Severity Score (ISS) of the 81 patients was 33.2 (11.4). The prevalence of TPP was higher in younger patients (p = 0.011), but the total number of fractured ribs was significantly lower (p = 0.001). In a subgroup analysis performed according to pseudocyst location, the intraparenchymal group had more severe injuries than the subpleural group (ISS, 23.3 vs. 32.4, p < 0.001; chest Abbreviated Injury Scale [AIS] score, 3.4 vs. 4.0, p < 0.001; number of associated injuries, 2.9 vs. 4.0, p = 0.001). By multivariate analysis, ISS, age, and number of associated injuries were significantly different in these two groups (p = 0.038, p = 0.006, and p = 0.045, respectively). The prevalence of TPP among cases of blunt chest trauma was 8.3% and was higher in those struck by a vehicle and younger patients. Intraparenchymal pseudocyst was found to be related to more severe injuries. TPP was a self-limiting condition that does not require specific treatment. Prognostic/epidemiologic study, level IV.

Trauma deaths in a mature urban trauma system: is "trimodal" distribution a valid concept?

PubMed

Demetriades, Demetrios; Kimbrell, Brian; Salim, Ali; Velmahos, George; Rhee, Peter; Preston, Christy; Gruzinski, Ginger; Chan, Linda

2005-09-01

Trimodal distribution of trauma deaths, described more than 20 years ago, is still widely taught in the design of trauma systems. The purpose of this study was to examine the applicability of this trimodal distribution in a modern trauma system. A study of trauma registry and emergency medical services records of trauma deaths in the County of Los Angeles was conducted over a 3-year period. The times from injury to death were analyzed according to mechanism of injury and body area (head, chest, abdomen, extremities) with severe trauma (abbreviated injury score [AIS] >/= 4). During the study period there were 4,151 trauma deaths. Penetrating trauma accounted for 50.0% of these deaths. The most commonly injured body area with critical trauma (AIS >/= 4) was the head (32.0%), followed by chest (20.8%), abdomen (11.5%), and extremities (1.8%). Time from injury to death was available in 2,944 of these trauma deaths. Overall, there were two distinct peaks of deaths: the first peak (50.2% of deaths) occurred within the first hour of injury. The second peak occurred 1 to 6 hours after admission (18.3% of deaths). Only 7.6% of deaths were late (>1 week), during the third peak of the classic trimodal distribution. Temporal distribution of deaths in penetrating trauma was very different from blunt trauma and did not follow the classic trimodal distribution. Other significant independent factors associated with time of death were chest AIS and head AIS. Temporal distribution of deaths as a result of severe head trauma did not follow any pattern and did not resemble classic trimodal distribution at all. The classic "trimodal" distribution of deaths does not apply in our trauma system. Temporal distribution of deaths is influenced by the mechanism of injury, age of the patient, and body area with severe trauma. Knowledge of the time of distribution of deaths might help in allocating trauma resources and focusing research effort.

Longest delayed hemothorax reported after blunt chest injury.

PubMed

Yap, Darren; Ng, Miane; Chaudhury, Madhu; Mbakada, Nik

2018-01-01

Blunt chest injury is a common presentation to the emergency department. However, a delayed hemothorax after blunt trauma is rare; current literature reports a delay of up to 30days. We present a case of 44-day delay in hemothorax which has not been previously reported in current literature. A 52-year-old Caucasian male first presented to the emergency department complaining of persistent right sided chest pain 2weeks after having slipped on a wet surface at home. His initial chest X-ray showed fractures of the right 7th and 8th ribs without a hemothorax or pneumothorax. He returned 30days after the initial consultation (44days post-trauma) having increasing shortness of breath. A chest X-ray this time revealed a large right hemothorax and 1850ml of blood drained from his chest. There was a complete resolution of the hemothorax within 48h and the patient was discharged after a 6-week follow-up with the chest physicians. Delayed hemothorax after blunt trauma is a rare clinical occurrence but associated with significant morbidity and mortality. The management of delayed hemothorax includes draining the hemothorax and controlling the bleeding. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be vigilant and weary that hemothorax could be a possibility after a chest injury despite a delay in presentation. A knowledge of delayed hemothorax will prompt physicians in providing important advice, warning signs and information to patients after a chest injury to avoid a delay in seeking medical attention. Copyright © 2017 Elsevier Inc. All rights reserved.

[Injury of subclavian artery in severe trauma of the shoulder girdle and chest].

PubMed

Samokhvalov, I M; Reva, V A; Pronchenko, A A; Petrov, A N

2013-01-01

The authors consider one of possible variants of surgical treatment of shoulder girdle trauma, which is accompanied by an injury of the main artery. It is based on the application of the principle of staged surgical treatment (damage control orthopedic). The well-timed sufficient diagnostics and treatment of bone-arterial trauma, coordinated work of several surgical teams, the appropriate postoperative management of patients with the using of postponed high-technology intervention allowed obtaining an optimal functional result for extremely severe multitrauma of the chest and limb.

The secrets of the unknown trauma patient. The hazards of undiagnosed subclavian steal syndrome in the chest trauma patient: a case report.

PubMed

Watemberg, S; Avrahami, R; Landau, O; Kott, I

1997-10-01

Chest trauma can be complicated, among others, with cardiac tamponade. This life-threatening condition should be treated promptly and adequately to assure a positive outcome. During the rapid events that take place in the emergency room with the arrival of a polytrauma patient, anamnestic data are not always available, especially if dealing with a non-cooperative, unaccompained traumatized patient. The following case report describes our experience with a chest trauma patient after a vehicle accident, who was admitted to our ward exhibiting a constellation of signs compatible with a cardiac tamponade. The only demonstrable objective signs included distended mediastinum and heart shadow on the chest X ray and muffled heart sounds. However, despite the impressive clinical picture, the patient continued to exhibit constant, though low blood pressure measurements and after a short period of observation, given the homodynamic stability, it was decided against pericardiocenthesis. The "secret" of our patient was finally discovered at angiography, when a left subclavian steal was diagnosed. The literature in this matter is discussed, stressing the importance of anamnestic data in the trauma patient. Most importantly, we address the significance of relying on hard clinical data (homodynamic stability) rather than on isolated signs (widened mediastinum/heart shadow) to reach as accurate a diagnosis as possible before pursuing invasive, usually not-innocuous procedures (pericardiocenthesis).

Surgical repair of right atrial wall rupture after blunt chest trauma.

PubMed

Telich-Tarriba, Jose E; Anaya-Ayala, Javier E; Reardon, Michael J

2012-01-01

Right atrial wall rupture after blunt chest trauma is a catastrophic event associated with high mortality rates. We report the case of a 24-year-old woman who was ejected 40 feet during a motor vehicle accident. Upon presentation, she was awake and alert, with a systolic blood pressure of 100 mmHg. Chest computed tomography disclosed a large pericardial effusion; transthoracic echocardiography confirmed this finding and also found right ventricular diastolic collapse. A diagnosis of cardiac tamponade with probable cardiac injury was made; the patient was taken to the operating room, where median sternotomy revealed a 1-cm laceration of the right atrial appendage. This lesion was directly repaired with 4-0 polypropylene suture. Her postoperative course was uneventful, and she continued to recover from injuries to the musculoskeletal system. This case highlights the need for a high degree of suspicion of cardiac injuries after blunt chest trauma. An algorithm is proposed for rapid recognition, diagnosis, and treatment of these lesions.

Major trauma from suspected child abuse: a profile of the patient pathway.

PubMed

Davies, Ffion C; Lecky, Fiona E; Fisher, Ross; Fragoso-Iiguez, Marisol; Coats, Tim J

2017-09-01

Networked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non-accidental injury is a significant cause of paediatric major trauma and has a different injury and age profile from accidental injury (AI). This paper compares the prehospital and inhospital phases of the patient pathway for children with suspected abuse, with those accidentally injured. The paediatric database of the national trauma registry of England and Wales, Trauma Audit and Research Network, was interrogated from April 2012 (the launch of the major trauma networks) to June 2015, comparing the patient pathway for cases of suspected child abuse (SCA) with AI. In the study population of 7825 children, 7344 (94%) were classified as AI and 481 (6%) as SCA. SCA cases were younger (median 0.4 years vs 7 years for AI), had a higher Injury Severity Score (median 16vs9 for AI), and had nearly three times higher mortality (5.7%vs2.2% for AI). Other differences included presentation to hospital evenly throughout the day and year, arrival by non-ambulance means to hospital (74%) and delayed presentation to hospital from the time of injury (median 8 hours vs 1.8 hours for AI). Despite more severe injuries, these infants were less likely to receive key interventions in a timely manner. Only 20% arrived to a designated paediatric-capable major trauma centre. Secondary transfer to specialist care, if needed, took a median of 21.6 hours from injury(vs 13.8 hours for AI). These data show that children with major trauma that is inflicted rather than accidental follow a different pathway through the trauma system. The current model of major trauma care is not a good fit for the way in which child victims of suspected abuse present to healthcare. To achieve better care, awareness of this patient profile needs to increase, and trauma networks should adjust their conventional responses. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Does fluoroscopy improve outcomes in paediatric forearm fracture reduction?

PubMed

Menachem, S; Sharfman, Z T; Perets, I; Arami, A; Eyal, G; Drexler, M; Chechik, O

2016-06-01

To compare the radiographic results of paediatric forearm fracture reduced with and without fluoroscopic enhancement to investigate whether fractures reduced under fluoroscopic guidance would have smaller residual deformities and lower rates of re-reduction and surgery. A retrospective cohort analysis was conducted comparing paediatric patients with acute forearm fracture in two trauma centres. Demographics and radiographic data from paediatric forearm fractures treated in Trauma Centre A with the aid of a C-arm fluoroscopy were compared to those treated without fluoroscopy in Trauma Centre B. Re-reduction, late displacement, post-reduction deformity, and need for surgical intervention were compared between the two groups. The cohort included 229 children (175 boys and 54 girls, mean age 9.41±3.2 years, range 1-16 years) with unilateral forearm fractures (83 manipulated with fluoroscopy and 146 without). Thirty-four (15%) children underwent re-reduction procedures in the emergency department. Fifty-three (23%) children had secondary displacement in the cast, of which 18 were operated on, 20 were re-manipulated, and the remaining 15 were kept in the cast with an acceptable deformity. Twenty-nine additional children underwent operation for reasons other than secondary displacement. There were no significant differences in re-reduction and surgery rates or in post-reduction deformities between the two groups. The use of fluoroscopy during reduction of forearm fractures in the paediatric population apparently does not have a significant effect on patient outcomes. Reductions performed without fluoroscopy were comparably accurate in correcting deformities in both coronal and sagittal planes. Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram.

PubMed

Mollberg, Nathan M; Wise, Stephen R; De Hoyos, Alberto L; Lin, Fang-Ju; Merlotti, Gary; Massad, Malek G

2012-06-01

Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention. A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed. In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period. The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Occult pneumothorax in Chinese patients with significant blunt chest trauma: incidence and management.

PubMed

Lee, Ka L; Graham, Colin A; Yeung, Janice H H; Ahuja, Anil T; Rainer, Timothy H

2010-05-01

Occult pneumothorax (OP) is a pneumothorax not visualised on a supine chest X-ray (CXR) but detected on computed tomography (CT) scanning. With increasing CT use for trauma, more OP may be detected. Management of OP remains controversial, especially for patients undergoing mechanical ventilation. This study aimed to identify the incidence of OP using thoracic CT as the gold standard and describe its management amongst Hong Kong Chinese trauma patients. Analysis of prospectively collected trauma registry data. Consecutive significantly injured trauma patients admitted through the emergency department (ED) suffering from blunt chest trauma who underwent thoracic computed tomography (TCT) between in calendar years 2007 and 2008 were included. An OP was defined as the identification (by a specialist radiologist) of a pneumothorax on TCT that had not been previously detected on supine CXR. 119 significantly injured patients were included. 56 patients had a pneumothorax on CXR and a further 36 patients had at least one OP [OP incidence 30% (36/119)]. Bilateral OP was present in 8/36 patients, so total OP numbers were 44. Tube thoracostomy was performed for 8/44 OP, all were mechanically ventilated in the ED. The remaining 36 OP were managed expectantly. No patients in the expectant group had pneumothorax progression, even though 8 patients required subsequent ventilation in the operating room for extrathoracic surgery. The incidence of OP (seen on TCT) in Chinese patients in Hong Kong after blunt chest trauma is higher than that typically reported in Caucasians. Most OP were managed expectantly without significant complications; no pneumothorax progressed even though some patients were mechanically ventilated. (c) 2010 Elsevier Ltd. All rights reserved.

How early should VATS be performed for retained haemothorax in blunt chest trauma?

PubMed

Lin, Hsing-Lin; Huang, Wen-Yen; Yang, Chyan; Chou, Shih-Min; Chiang, Hsin-I; Kuo, Liang-Chi; Lin, Tsung-Ying; Chou, Yi-Pin

2014-09-01

Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood. In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2-3 days (Group 1), 4-6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups. The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference. This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile.

PubMed

De Rezende Neto, João Baptista; Guimarães, Tiago Nunes; Madureira, João Lopo; Drumond, Domingos André Fernandes; Leal, Juliana Campos; Rocha, Aroldo; Oliveira, Rodrigo Guimarães; Rizoli, Sandro B

2009-05-01

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent. We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury. Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis. Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Management of paediatric splenic injury in the New South Wales trauma system.

PubMed

Adams, Susan E; Holland, Andrew; Brown, Julie

2017-01-01

Since the 1980's, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere. To investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year. Children age 0-16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000-December 2005) and most recent (January 2006-December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders. 955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01-1.18, p<0.05), massive splenic disruption (OR 3.10, 95% CI 1.61-6.19, p<0.001), hollow viscus injury (OR 11.03, 95% CI 3.46-34.28, p<0.001) and transfusion (OR 7.70, 95% CI 4.54-13.16, p<0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70-10.52, p<0.01), rural trauma centre (OR 3.72 95% CI 1.83-7.83, p<0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22-18.93 p<0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89-243 p=0.13) CONCLUSION: While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required. Copyright © 2016 Elsevier Ltd. All rights reserved.

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study.

PubMed

Langdorf, Mark I; Medak, Anthony J; Hendey, Gregory W; Nishijima, Daniel K; Mower, William R; Raja, Ali S; Baumann, Brigitte M; Anglin, Deirdre R; Anderson, Craig L; Lotfipour, Shahram; Reed, Karin E; Zuabi, Nadia; Khan, Nooreen A; Bithell, Chelsey A; Rowther, Armaan A; Villar, Julian; Rodriguez, Robert M

2015-12-01

Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Outcome of Concurrent Occult Hemothorax and Pneumothorax in Trauma Patients Who Required Assisted Ventilation

PubMed Central

Mahmood, Ismail; Tawfeek, Zainab; El-Menyar, Ayman; Zarour, Ahmad; Afifi, Ibrahim; Kumar, Suresh; Latifi, Rifat; Al-Thani, Hassan

2015-01-01

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise. PMID:25785199

Impacted thoracic foreign bodies after penetrating chest trauma.

PubMed

Sersar, Sameh I; Albohiri, Khalid A; Abdelmohty, Hysam

2016-10-01

Retained foreign bodies in the chest may include shell fragments, bullets, shrapnel, pieces of clothing, bones, and rib fragments. The risks of removal of foreign bodies must be weighed against the complications of leaving them inside the chest. We treated 90 cases of retained intrathoracic foreign bodies in patients admitted to 3 tertiary centers in Saudi Arabia between March 2015 and March 2016. Sixty patients were injured by shrapnel, 26 had one or more bullets, 3 had broken rib fragments, and one had a metal screw. The chest wall was site of impaction in 48 cases, the lungs in 24, pleura in 14, and mediastinum in 4. Removal of the retained foreign body was carried out in 12 patients only: bullets in 9 cases, bone fragments in 2, and a metal screw in one. The predictors for removal were bullets, female sex, and mediastinal position with bilateral chest injury, especially with fracture ribs. Retained intrathoracic foreign bodies due to penetrating chest trauma are treated mainly conservatively unless there is another indication for chest exploration. © The Author(s) 2016.

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center.

PubMed

Onat, Serdar; Ulku, Refik; Avci, Alper; Ates, Gungor; Ozcelik, Cemal

2011-09-01

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality. A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded. A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 9.33 (range, 15–54) years. The mean LOS was 10.65 8.30 (range, 5–65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 9.92 days; stab wound, 8.76 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 36.702 mm Hg) compared with those who survived (83.96 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality. Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.

Thin chest wall is an independent risk factor for the development of pneumothorax after chest tube removal.

PubMed

Anand, Rahul J; Whelan, James F; Ferrada, Paula; Duane, Therese M; Malhotra, Ajai K; Aboutanos, Michel B; Ivatury, Rao R

2012-04-01

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the "protective" layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Does intrapleural length and position of the intercostal drain affect the frequency of residual hemothorax? A prospective study from north India

PubMed Central

Kumar, Sunil; Agarwal, Nitin; Rattan, Amulya; Rathi, Vinita

2014-01-01

Context: Thoracic trauma causes significant morbidity; however, many deaths are preventable and few patients require surgery. Intercostal chest drainage (ICD) for hemo/pneumothorax is simple and effective; the main problem is residual hemothorax, which can cause lung collapse and empyema. Aims: Our study aimed to analyze the relationship between radiological chest tube parameters (position and intrathoracic length) and the frequency of residual hemothorax. Settings and Design: This prospective analytical study was conducted in a large tertiary care hospital in north India over 2 years till March 2013. Materials and Methods: Patients of chest trauma aged 18-60 years, with hemothorax or hemopneumothorax requiring ICD insertion were included in the study. Bedside ICD insertion was performed as per current standards. Immediate post-ICD chest radiographs were used to record lung status and ICD position (chest tube zone and intrapleural length). Residual hemothorax was defined as any collection identified on radiological investigations after 48 hours of ICD placement. Statistical Analysis: Univariate analysis was performed with the chi-square test or Student's t-test as appropriate, while multivariate analysis using stepwise logistic regression; a P-value < 0.05 was significant. Results: Out of 170 patients of chest trauma, 154 underwent ICD insertion. Most patients were young (mean age: 31.7 ± 12 years) males (M:F = 14:1). Ninety-seven patients (57.1%) had isolated chest injuries. Blunt trauma (n = 119; 77.3%) and motor vehicle accidents (n = 72; 46.7%) were the commonest causes. Mean hospital stay was 9 ± 3.94 days, and mortality 2/154 (1.1%). Residual hemothorax was seen in 48 (31%). No ICD zone or length was significantly associated with residual hemothorax on univariate or multivariate analysis. Conclusion: Intrapleural ICD zone or length does not affect the frequency of residual hemothorax. PMID:25400388

Risk factors associated with the severity of injury outcome for paediatric road trauma.

PubMed

Mitchell, R J; Bambach, M R; Foster, K; Curtis, K

2015-05-01

Road trauma is one of the most common causes of injury for children. Yet risk factors associated with different levels of injury severity for childhood road trauma have not been examined in-depth. This study identifies crash and injury risk factors associated with the severity of non-fatal injury outcome for paediatric road trauma. A retrospective analysis was conducted of paediatric road trauma identified in linked police-reported and hospitalisation records during 1 January 2001 to 31 December 2011 in New South Wales (NSW), Australia. The linkage rate was 54%. Injury severity was calculated from diagnosis classifications in hospital records using the International Classification of Disease Injury Severity Score. Univariate and multi-variable logistic regression was conducted. There were 2412 car occupants, 1701 pedestrians and 612 pedal cyclists hospitalised where their hospital record linked to a police report. For car occupants, unauthorised vehicle drivers had twice the odds (OR: 2.21, 95%CI 1.47-3.34) and learner/provisional drivers had one and a half times higher odds (OR: 1.54, 95%CI 1.15-2.07) of a child car occupant sustaining a serious injury compared to a minor injury. For pedal cyclists and pedestrians, there were lower odds of a crash occurring during school commuting time and higher odds of a crash occurring during the weekend or on a dry road for children who sustained a serious versus a minor injury. Injury prevention initiatives, such as restraint and helmet use, that should reduce injury and/or crash severity are advocated. Copyright © 2015 Elsevier Ltd. All rights reserved.

Perspectives of hospital emergency department staff on trauma-informed care for injured children: An Australian and New Zealand analysis.

PubMed

Hoysted, Claire; Babl, Franz E; Kassam-Adams, Nancy; Landolt, Markus A; Jobson, Laura; Curtis, Sarah; Kharbanda, Anupam B; Lyttle, Mark D; Parri, Niccolò; Stanley, Rachel; Alisic, Eva

2017-09-01

To examine Australian and New Zealand emergency department (ED) staff's training, knowledge and confidence regarding trauma-informed care for children after trauma, and barriers to implementation. ED staff's perspectives on trauma-informed care were assessed using a web-based self-report questionnaire. Participants included 468 ED staff (375 nursing and 111 medical staff) from hospitals in Australia and New Zealand. Data analyses included descriptive statistics, χ 2 tests and multiple regressions. Over 90% of respondents had not received training in trauma-informed care and almost all respondents (94%) wanted training in this area. While knowledge was associated with a respondent's previous training and profession, confidence was associated with the respondent's previous training, experience level and workplace. Dominant barriers to the implementation of trauma-informed care were lack of time and lack of training. There is a need and desire for training and education of Australian and New Zealand ED staff in trauma-informed care. This study demonstrates that experience alone is not sufficient for the development of knowledge of paediatric traumatic stress reactions and trauma-informed care practices. Existing education materials could be adapted for use in the ED and to accommodate the training preferences of Australian and New Zealand ED staff. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Left atrial thrombus as an early consequence of blunt chest trauma

PubMed Central

Mahy, I; Al-Mohammad, A; Cargill, R

1998-01-01

Thromboembolism is rarely considered in discussions of the complications of blunt chest trauma. The few cases of thromboembolism that have been reported in this setting have occurred in association with significant myocardial damage. A previously fit 23 year old woman was admitted to the intensive care unit following a road traffic accident. A day later, left atrial thrombus was demonstrated by transoesophageal echocardiography in the absence of any other evidence of important myocardial injury. Anticoagulation with heparin was cautiously introduced in spite of her extensive injuries, and there were no consequent bleeding complications. At hospital discharge on day 18 she was entirely well. Full anticoagulation with warfarin was continued for a further eight weeks at which time follow up transoesophageal echocardiography showed complete resolution of the thrombus.

 Keywords: blunt chest trauma;  thromboembolism;  left atrial thrombus;  transoesophageal echocardiography PMID:9538317

Questionnaire-based study showed that neonatal chest radiographs could be reliably interpreted using the WhatsApp messaging application.

PubMed

Gross, Itai; Langer, Yshia; Pasternak, Yehonatan; Abu Ahmad, Wiessam; Eventov-Friedman, Smadar; Koplewitz, Benjamin Z

2018-06-11

We surveyed whether clinicians used the WhatsApp messaging application to view neonatal chest radiographs and asked a sub-sample to compare them with computer screen viewings. The study was conducted at three university-affiliated medical centres in Israel from June-December 2016. Questionnaires on using smartphones for professional purposes were completed by 68/71 paediatric residents and 20/28 neonatologists. In addition, 11 neonatologists viewed 20 chest radiographs on a computer screen followed by a smartphone and 10 viewed the same radiographs in the opposite order, separated by a washout period of two months. After another two months, five from each group viewed the same radiographs on a computer screen. Different interpretations between viewing modes were assessed. Most respondents used WhatsApp to send chest radiographs for consultation: 82% of the paediatric residents and 80% of the neonatologists. The mean number of inconsistencies in diagnosis was 3.7/20 between two computer views and 2.9/20 between computer and smartphone views (p=0.88) and the disease severity means were 3.7/20 and 2.85/20, respectively (p=0.94). Neonatologists using WhatsApp only determined umbilical line placement in 80% of cases. WhatsApp was reliable for preliminary interpretation of neonatal chest radiographs, but caution was needed when assessing umbilical lines. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Delayed massive hemothorax complicating simple rib fracture associated with diaphragmatic injury.

PubMed

Chen, Chin-Li; Cheng, Yeung-Leung

2014-07-01

Traumatic hemothorax is potentially life threatening. Rib fractures are the commonest injury after chest trauma, which accounts for 10% of patients after trauma. A delayed massive hemothorax after simple rib fracture is rare. The possibility of delayed sequelae after chest trauma should be considered, and patients should be informed of this possibility. We present a case of this uncommon situation with delayed massive hemothorax caused by simple fracture of the lower ribs. Admission should be considered for close observation when presenting with fracture of the lower ribs because of the possibility of diaphragmatic injury or intra-abdominal injury, even if a simple rib fracture is found initially.

[Video-assisted thoracoscopic surgery as an alternative to urgent thoracotomy following open chest trauma in selected cases].

PubMed

Samiatina, Diana; Rubikas, Romaldas

2004-01-01

To prove that video-assisted thoracoscopic surgery in selected cases is an alternative to urgent thoracotomy following open chest trauma. Retrospective analysis of case reports of patients operated for open chest trauma during 1997-2002. Comparison of two methods of surgical treatment: urgent video-assisted thoracoscopy and urgent thoracotomy. Duration of drain presence in the pleural cavity, duration of postoperative treatment, pain intensity and cosmetic effect were evaluated. Data analysis was performed using SPSS statistical software. Statistical evaluation of differences between groups was performed using Mann-Whitney U test. The differences between groups were considered to be statistically significant when the probability of deviation was p<0.05. During 1997-2002, 121 patients with open chest trauma were operated. Thirty three patients underwent urgent video-assisted thoracoscopy, 88 patients were operated through thoracotomy incision: 69 due to isolated open chest trauma, 17 due to thoracoabdominal injury and 2 due to abdominothoracic injury. Almost thirteen percent (12.5%) of patients after urgent thoracotomy underwent urgent laparotomy due to damaged diaphragm and other organs of peritoneal cavity. Duration of drain presence in the pleural cavity after video-assisted thoracoscopy was 4.57 days and after urgent thoracotomy - 6.88 days (p<0.05). Duration of post-operative treatment after video-assisted thoracoscopy was 8.21 days and after urgent thoracotomy - 14.89 days (p<0.05). Amount of consumed non-narcotic analgesics after video-assisted thoracoscopy was 1056.98 mg and after urgent thoracotomy - 1966.70 mg (p<0.05). Video-assisted thoracoscopy is minimally invasive method of thoracic surgery allowing for the evaluation of the pathological changes in the lung, pericardium, diaphragm, mediastinum, thoracic wall and pleura, including the localization of these changes, and the type and severity of the injury. The number of early post-operative complications following video-assisted thoracoscopy is lower. Compared to operations through thoracotomy incision, video assisted thoracoscopies entail the shortening of the duration of drain presence in the pleural cavity and the duration of post-operative treatment. Video-assisted thoracoscopy should be performed on all patients with open chest trauma and stable hemodynamics and the respiration function. Video-assisted thoracoscopy is an informative diagnostic and treatment method allowing for the selection of patients for urgent thoracotomy.

Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis.

PubMed

Battle, Ceri E; Hutchings, Hayley; Evans, Phillip A

2012-01-01

The risk factors for mortality following blunt chest wall trauma have neither been well established or summarised. To summarise the risk factors for mortality in blunt chest wall trauma patients based on available evidence in the literature. A systematic review of English and non-English articles using MEDLINE, EMBASE and the Cochrane Library from their introduction until May 2010. Additional studies were identified by hand-searching bibliographies and contacting relevant clinical experts. Grey literature was sought by searching abstracts from all Emergency Medicine conferences. Broad search terms and inclusion criteria were used to reduce the number of missed studies. A two step study selection process was used. All published and unpublished observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. A two step data extraction process using pre-defined data fields, including study quality indicators. Each study was appraised using a previously designed quality assessment tool and the STROBE checklist. Where sufficient data were available, odds ratios with 95% confidence intervals were calculated using Mantel-Haenszel method for the risk factors investigated. The I(2) statistic was calculated for combined studies in order to assess heterogeneity. Age, number of rib fractures, presence of pre-existing disease and pneumonia were found to be related to mortality in 29 identified studies. Combined odds ratio of 1.98 (1.86-2.11, 95% CI), 2.02 (1.89-2.15, 95% CI), 2.43 (1.03-5.72, 95% CI) and 5.24 (3.51-7.82) for mortality were calculated for blunt chest wall trauma patients aged 65 years or more, with three or more rib fractures, pre-existing conditions and pneumonia respectively. The risk factors for mortality in patients sustaining blunt chest wall trauma were a patient age of 65 years or more, three or more rib fractures and the presence of pre-existing disease especially cardiopulmonary disease. The development of pneumonia post injury was also a significant risk factor for mortality. As a result of the variable quality in the studies, the results of the selected studies should be interpreted with caution. Copyright © 2011 Elsevier Ltd. All rights reserved.

SU-E-P-57: Radiation Doses Assessment to Paediatric Patients for Some Digital Diagnostic Radiology Examination in Emergency Department in Qatar

DOE Office of Scientific and Technical Information (OSTI.GOV)

Abdallah, I; Aly, A; Al Naemi, H

Purpose: The aim of this study was to evaluate radiation doses to pediatric patients undergoing standard radiographic examinations using Direct Digital Radiography (DDR) in Paediatric emergency center of Hamad General Hospital (HGH) in state of Qatar and compared with regional and international Dose Reference Levels (DRLs). Methods: Entrance Skin Dose (ESD) was measured for 2739 patients for two common X-ray examinations namely: Chest AP/PA, Abdomen. Exposure factors such as kV, mAs and Focal to Skin Distance (FSD) were recorded for each patient. Tube Output was measured for a range of selected kV values. ESD for each individual patient was calculatedmore » using the tube output and the technical exposure factors for each examination. The ESD values were compared with the some international Dose Reference Levels (DRL) for all types of examinations. Results: The most performed procedure during the time of this study was chest PA/PA (85%). The mean ESD values obtained from AP chest, PA chest and AP abdomen ranged 91–120, 80–84 and 209 – 659 µGy per radiograph for different age’s groups respectively. Two protocols have been used for chest AP and PA using different radiological parameters, and the different of ESD values for chest PA and were 41% for 1 years old child, 57% for 5 years old for chest AP. Conclusion: The mean ESD were compared with those found in literature and were found to be comparable. The radiation dose can be reduced more for Chest AP and PA examination by optimization of each investigation and hence more studies are required for this task. The results presented will serve as a baseline data needed for deriving local reference doses for pediatric X-ray examinations in this local department and hence it can be applied in the whole Qatar.« less

Validation of the Australian diagnostic reference levels for paediatric multi detector computed tomography: a comparison of RANZCR QUDI data and subsequent NDRLS data from 2012 to 2015.

PubMed

Anna, Hayton; Wallace, Anthony; Thomas, Peter

2017-03-01

The national diagnostic reference level service (NDRLS), was launched in 2011, however no paediatric data were submitted during the first calendar year of operation. As such, Australian national diagnostic reference levels (DRLs), for paediatric multi detector computed tomography (MDCT), were established using data obtained from a Royal Australian and New Zealand College of Radiologists (RANZCR), Quality Use of Diagnostic Imaging (QUDI), study. Paediatric data were submitted to the NDRLS in 2012 through 2015. An analysis has been made of the NDRLS paediatric data using the same method as was used to analyse the QUDI data to establish the Australian national paediatric DRLs for MDCT. An analysis of the paediatric NDRLS data has also been made using the method used to calculate the Australian national adult DRLs for MDCT. A comparison between the QUDI data and subsequent NDRLS data shows the NDRLS data to be lower on average for the Head and AbdoPelvis protocol and similar for the chest protocol. Using an average of NDRLS data submitted between 2012 and 2015 implications for updated paediatric DRLS are considered.

Large pneumothorax in blunt chest trauma: Is a chest drain always necessary in stable patients? A case report.

PubMed

Idris, Baig M; Hefny, Ashraf F

2016-01-01

Pneumothorax is the most common potentially life-threatening blunt chest injury. The management of pneumothorax depends upon the etiology, its size and hemodynamic stability of the patient. Most clinicians agree that chest drainage is essential for the management of traumatic large pneumothorax. Herein, we present a case of large pneumothorax in blunt chest trauma patient that resolved spontaneously without a chest drain. A 63- year- old man presented to the Emergency Department complaining of left lateral chest pain due to a fall on his chest at home. On examination, he was hemodynamically stable. An urgent chest X-ray showed evidence of left sided pneumothorax. CT scan of the chest showed pneumothorax of more than 30% of the left hemithorax (around 600ml of air) with multiple left ribs fracture. Patient refused tube thoracostomy and was admitted to surgical department for close observation. The patient was managed conservatively without chest tube insertion. A repeat CT scan of the chest has shown complete resolution of the pneumothorax. The clinical spectrum of pneumothorax varies from asymptomatic to life threatening tension pneumothorax. In stable patients, conservative management can be safe and effective for small pneumothorax. To the best of our knowledge, this is the second reported case in the English literature with large pneumothorax which resolved spontaneously without chest drain. Blunt traumatic large pneumothorax in a clinically stable patient can be managed conservatively. Current recommendations for tube placement may need to be reevaluated. This may reduce morbidity associated with chest tube thoracostomy. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Esophageal perforation due to blunt chest trauma: Difficult diagnosis because of coexisting severe disturbance of consciousness.

PubMed

Mezuki, Satomi; Shono, Yuji; Akahoshi, Tomohiko; Hisanaga, Kana; Saeki, Hiroshi; Nakashima, Yuichiro; Momii, Kenta; Maki, Jun; Tokuda, Kentaro; Maehara, Yoshihiko

2017-11-01

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis. Copyright © 2017 Elsevier Inc. All rights reserved.

Does Video Laryngoscopy Offer Advantages over Direct Laryngoscopy during Cardiopulmonary Resuscitation?

PubMed

Saraçoğlu, Ayten; Bezen, Olgaç; Şengül, Türker; Uğur, Egin Hüsnü; Şener, Sibel; Yüzer, Fisun

2015-08-01

Interruption of chest compressions should be minimized because of its negative effects on survival. This randomized, controlled, cross-over study aimed to analyze the effectiveness of Macintosh, Miller, McCoy and McGrath laryngoscopes during with or without chest compressions in the scope of a simulated cardiopulmonary resuscitation scenario. The time required for successful tracheal intubation, number of attempts, dental trauma severity and the need for optimization manoeuvres were recorded during cardiopulmonary resuscitation with and without chest compressions. The experience with computer games during the last 10 years were asked to the participants and recorded. McCoy laryngoscope yielded the shortest time for successful tracheal intubation both in the presence of and without chest compressions. During the use of McCoy laryngoscopes, fewer tracheal intubation attempts, lower incidence of dental trauma and lower visual analogue scale scores on the ease of intubation were recorded. Participants who are experienced computer game players using Macintosh, McCoy and McGrath achieved successful tracheal intubation in a significantly shorter time during resuscitation without chest compressions. Dental trauma incidence and number of tracheal intubation attempts did not show any significant difference between the four laryngoscopes being related to the rate of playing computer games. McGrath video laryngoscopes do not appear to have advantages over direct laryngoscopes for securing a smooth and successful tracheal intubation during rhythmic chest compressions. We believe that as McCoy laryngoscope provided tracheal intubation in a shorter time and with fewer attempts, this laryngoscope may increase the success rate of resuscitation.

Routine transesophageal echocardiography for the diagnosis of aortic disruption in trauma patients without enlarged mediastinum.

PubMed

Vignon, P; Lagrange, P; Boncoeur, M P; Francois, B; Gastinne, H; Lang, R M

1996-03-01

To assess the value of routine transesophageal echocardiography (TEE) in diagnosing traumatic disruption of the aorta (TDA) in trauma patients presenting without enlarged mediastinum on chest x-ray films. Prospective study. TEE was routinely performed to exclude the presence of TDA in patients who sustained severe trauma secondary to abrupt deceleration collisions and presented with an upper mediastinum of fewer than 8 cm on supine chest x-ray films. Patients were divided into two groups according to the presence (group I) or absence (group II) of mediastinal hematoma diagnosed during TEE examination. Radiographic signs regarded as indicators of the presence of TDA were evaluated in both groups. Among the 40 consecutive patients studied, TEE demonstrated two cases of TDA associated with a mediastinal hematoma that were confirmed by both aortography and surgery. One of the patients had a normal mediastinum on presentation chest x-ray films, and the other only exhibited a blurred aortic knob. Radiographic mediastinal abnormalities suggestive of TDA were observed in 13 patients, but chest x-ray films were unremarkable in 12 patients. Twenty patients had multiple rib fractures. The frequency of chest radiographic abnormalities was not significantly higher in group I (n = 6) when compared with group II patients (n = 34). TEE examination demonstrated a normal thoracic aorta in 35 patients and was nondiagnostic in 3 patients (normal aortography). TEE should be routinely performed in victims of violent deceleration collisions, even in patients presenting apparently normal mediastinum on supine chest radiography.

Trauma in Auckland: an overview.

PubMed

Streat, S J; Donaldson, M L; Judson, J A

1987-07-22

Data are presented on all 569 subjects who, as a result of trauma, either died or were admitted to hospital in Auckland over a four week period. Median age was 23 with an overall 3:2 male:female ratio. Median injury severity score (ISS) was five with 9% of subjects having an ISS of 16 or more (major trauma). Blunt trauma accounted for 84% of all injuries. Life threatening injuries were most commonly to the head, thorax and abdomen while the largest number of less severe injuries were to the extremities. Eight subjects died before admission to hospital and a further six in hospital. Definitive care was given to 98% of patients at Middlemore and Auckland hospitals (including the onsite Princess Mary paediatric facility) but 26% had presented first to other hospitals and 43% of all patients were transferred from one hospital to another. The 561 patients used 6380 hospital days (including 314 intensive care days) and the following services--operating room 63%, orthopaedic ward 45%, plastic surgical ward 17%, paediatric ward 15%, neurosurgical ward 10%, general surgical ward 5%, intensive care 5% and CT scanner 4%. Only one hospital death was judged potentially preventable. This study reveals areas where trauma care could be improved, demonstrates the large amount of hospital resources required to treat trauma and particularly highlights the urgent need for studies into strategies for trauma prevention in New Zealand.

Orem's Self-Care Model With Trauma Patients: A Quasi-Experimental Study.

PubMed

Khatiban, Mahnaz; Shirani, Fatemeh; Oshvandi, Khodayar; Soltanian, Ali Reza; Ebrahimian, Ramin

2018-07-01

To examine if the application of Orem's self-care model could improve self-care knowledge, attitudes, practices, and respiratory conditions of trauma patients with chest tubes, a quasi-experimental study was conducted. The participants were assigned to two groups-namely, Orem's model and routine care. Although the patients' self-care knowledge, attitudes, and practices were improved in both groups over the course of 3 days since the initial assessments, there was a greater degree of improvement in the experimental group than that in the control group. However, there were no differences in the improvement of the chest parameters between the two groups. Orem's model was effective in improving self-care in patients with chest tube.

Emergency thoracotomy. Care of the patient in the OR: a case study.

PubMed

Singer, N

1987-12-01

As an OR staff nurse at Cook County Hospital, some of my most challenging and rewarding nursing experiences have come from caring for emergency open-chest trauma patients. From the moment we receive a call that an open-chest patient is on the way, everyone assigned is in a high state of tension. Every decision takes on exaggerated importance. The circulating nurse, by virtue of his or her position during an emergency, is the "hub of the wheel" of activity. He or she is privy to all facets of care that are being administered to the patient. The nursing challenge of the emergency open-chest trauma is great, but it is not an impossible task.

Acute haemorrhagic oedema of infancy in a 5-week-old boy referred to the Child Protection Unit.

PubMed

Hawkrigg, Sharon; Johnson, Alice; Flynn, James; Thom, Graham; Wright, Helen

2014-06-01

We describe the case of a 5-week-old infant boy presenting with purpura and oedema to both hands and torso. He was otherwise well, with no antecedent history of illness or trauma. Laboratory investigations were within normal limits. A review by the Child Protection Unit was organised during his admission for consideration of inflicted trauma as a cause of the lesions; this was felt most unlikely. A clinical diagnosis, following a dermatology consultation, of acute haemorrhagic oedema of infancy (AHO) was made. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma.

PubMed

Huang, Fong-Dee; Yeh, Wen-Bin; Chen, Sheng-Shih; Liu, Yuan-Yuarn; Lu, I-Yin; Chou, Yi-Pin; Wu, Tzu-Chin

2018-01-05

Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3-4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05). In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.

Mitral valve plasty for mitral regurgitation after blunt chest trauma.

PubMed

Kumagai, H; Hamanaka, Y; Hirai, S; Mitsui, N; Kobayashi, T

2001-06-01

A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.

Mechanisms, patterns and outcomes of paediatric polytrauma in a UK major trauma centre.

PubMed

Naqvi, G; Johansson, G; Yip, G; Rehm, A; Carrothers, A; Stöhr, K

2017-01-01

Introduction Paediatric trauma is a significant burden to healthcare worldwide and accounts for a large proportion of deaths in the UK. Methods This retrospective study examined the epidemiological data from a major trauma centre in the UK between January 2012 and December 2014, reviewing all cases of moderate to severe trauma in children. Patients were included if aged ≤16 years and if they had an abbreviated injury scale score of ≥2 in one or more body region. Results A total of 213 patients were included in the study, with a mean age of 7.8 years (standard deviation [SD]: 5.2 years). The most common cause of injury was vehicle related incidents (46%). The median length of hospital stay was 5 days (interquartile range [IQR]: 4-10 days). Approximately half (52%) of the patients had to stay in the intensive care unit, for a median of 1 day (IQR: 0-2 days). The mortality rate was 6.6%. The mean injury severity score was 19 (SD: 10). Pearson's correlation coefficient showed a positive correlation for injury severity score with length of stay in hospital (p<0.001). Conclusions There is significant variation in mechanism of injury, severity and pattern of paediatric trauma across age groups. A multidisciplinary team approach is imperative, and patients should be managed in specialist centres to optimise their care and eventual functional recovery. Head injury remained the most common, with significant mortality in all age groups. Rib fractures and pelvic fractures should be considered a marker for the severity of injury, and should alert doctors to look for other associated injuries.

Trauma care at rural level III trauma centers in a state trauma system.

PubMed

Helling, Thomas S

2007-02-01

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care. During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail. A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5. Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline.

PubMed

Soccorso, Giampiero; Anbarasan, Ravindar; Singh, Michael; Lindley, Richard M; Marven, Sean S; Parikh, Dakshesh H

2015-12-01

Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres. Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015. Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy. Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy.

PubMed

Helling, T S; Gyles, N R; Eisenstein, C L; Soracco, C A

1989-10-01

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

[Sleeve resection of right main bronchus for posttraumatic bronchial stenosis].

PubMed

Bobocea, Andrei Cristian; Matache, Radu; Codreşi, Mihaela; Bolca, Ciprian; Cordoş, Ioan

2011-01-01

Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. A high index of clinical suspicion and accurate interpretation of radiological findings are necessary for prompt surgical intervention with primary repair of the airway. Delays in treatment increases the risk of partial to complete bronchial stenosis. A 21 years old male was admitted to our hospital following a workplace accident. A chest radiograph showed bilateral pneumothorax, cephalic and mediastinal emphysema. Chest tubes were placed on each side, with full pulmonary expansion and remission of emphysema. Minimal lesions of the right main bronchus were found at fiberoptic bronchoscopy. Daily chest X-rays showed an uncomplicated recovery. A stenosis was suspected due to right lung pneumonia evolving under specific antibiotherapy. Right main bronchus posttraumatic stricture was diagnosed by fiberoptic bronchoscopy. He underwent a right lateral thoracotomy with sleeve resection of stenotic bronchi. Control bronchoscopy reveals main bronchus widely patent with untraceable suture line. Main bronchus rupture in blunt chest trauma is an additive effect of chest wall compression between two solid surfaces, traction on the carina and sudden increase in intraluminal pressure. Symptoms may vary: soft air leak, pneumothorax or limited mediastinal emphysema. Bronchoscopy should be performed immediately or when available. Granulation tissue leads to progressive bronchial obstruction, with distal infection and permanent parenchymal damage. Sleeve resection of the stenosed segment is the treatment of choice and restores fully the lung function. Rupture of main bronchus is a complication of blunt chest trauma. Flexible bronchoscopy is useful and reliable for early diagnosis of traumatic tracheobronchial injuries. Delayed diagnosis can lead to lung parenchyma alteration due to retrostenotic pneumonia. Resection and end-to-end anastomosis is the key of successful in these cases.

[Rib cage ostheosynthesis. Literature review and case reports].

PubMed

Jiménez-Quijano, Andrés; Varón-Cotés, Juan Carlos; García-Herreros-Hellal, Luis Gerardo; Espinosa-Moya, Beatriz; Rivero-Rapalino, Oscar; Salazar-Marulanda, Michelle

2015-01-01

Fractures of the chest wall include sternum and rib fractures. Traditionally they are managed conservatively due to the anatomy of the rib cage that allows most of them to remain stable and to form a callus that unites the fractured segments. In spite of this management, some patients present with chronic pain or instability of the wall which makes them require some type of fixation. The present article performs a literature review based on 4 cases. The first case was a 61 year-old man with blunt chest trauma, with a great deformity of the chest wall associated with subcutaneous emphysema, and pneumothorax. The second case was a 51 year-old man with blunt chest trauma, initially managed at another institution, who despite treatment, had persistent pain and dyspnoea. The third case was a 30 year-old man that suffered a motor vehicle accident, with resulting pain and crepitation of the rib cage and with diagnostic images showing multiple rib fractures. The last case is a 62 year-old man that fell down the stairs, with blunt chest trauma with high intensity pain, dyspnoea and basal ipsilateral hypoventilation. Rib fracture fixation offers a good alternative in selected patients to decrease associated morbidity, leading to a patient's fast return to his or her working life. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Computed Tomography Window Blending: Feasibility in Thoracic Trauma.

PubMed

Mandell, Jacob C; Wortman, Jeremy R; Rocha, Tatiana C; Folio, Les R; Andriole, Katherine P; Khurana, Bharti

2018-02-07

This study aims to demonstrate the feasibility of processing computed tomography (CT) images with a custom window blending algorithm that combines soft-tissue, bone, and lung window settings into a single image; to compare the time for interpretation of chest CT for thoracic trauma with window blending and conventional window settings; and to assess diagnostic performance of both techniques. Adobe Photoshop was scripted to process axial DICOM images from retrospective contrast-enhanced chest CTs performed for trauma with a window-blending algorithm. Two emergency radiologists independently interpreted the axial images from 103 chest CTs with both blended and conventional windows. Interpretation time and diagnostic performance were compared with Wilcoxon signed-rank test and McNemar test, respectively. Agreement with Nexus CT Chest injury severity was assessed with the weighted kappa statistic. A total of 13,295 images were processed without error. Interpretation was faster with window blending, resulting in a 20.3% time saving (P < .001), with no difference in diagnostic performance, within the power of the study to detect a difference in sensitivity of 5% as determined by post hoc power analysis. The sensitivity of the window-blended cases was 82.7%, compared to 81.6% for conventional windows. The specificity of the window-blended cases was 93.1%, compared to 90.5% for conventional windows. All injuries of major clinical significance (per Nexus CT Chest criteria) were correctly identified in all reading sessions, and all negative cases were correctly classified. All readers demonstrated near-perfect agreement with injury severity classification with both window settings. In this pilot study utilizing retrospective data, window blending allows faster preliminary interpretation of axial chest CT performed for trauma, with no significant difference in diagnostic performance compared to conventional window settings. Future studies would be required to assess the utility of window blending in clinical practice. Copyright © 2018 The Association of University Radiologists. All rights reserved.

Simple X-ray versus ultrasonography examination in blunt chest trauma: effective tools of accurate diagnosis and considerations for rib fractures.

PubMed

Hwang, Eun Gu; Lee, Yunjung

2016-12-01

Simple radiography is the best diagnostic tool for rib fractures caused by chest trauma, but it has some limitations. Thus, other tools are also being used. The aims of this study were to investigate the effectiveness of ultrasonography (US) for identifying rib fractures and to identify influencing factors of its effectiveness. Between October 2003 and August 2007, 201 patients with blunt chest trauma were available to undergo chest radiographic and US examinations for diagnosis of rib fractures. The two modalities were compared in terms of effectiveness based on simple radiographic readings and US examination results. We also investigated the factors that influenced the effectiveness of US examination. Rib fractures were detected on radiography in 69 patients (34.3%) but not in 132 patients. Rib fractures were diagnosed by using US examination in 160 patients (84.6%). Of the 132 patients who showed no rib fractures on radiography, 92 showed rib fractures on US. Among the 69 patients of rib fracture detected on radiography, 33 had additional rib fractures detected on US. Of the patients, 76 (37.8%) had identical radiographic and US results, and 125 (62.2%) had fractures detected on US that were previously undetected on radiography or additional fractures detected on US. Age, duration until US examination, and fracture location were not significant influencing factors. However, in the group without detected fractures on radiography, US showed a more significant effectiveness than in the group with detected fractures on radiography ( P =0.003). US examination could detect unnoticed rib fractures on simple radiography. US examination is especially more effective in the group without detected fractures on radiography. More attention should be paid to patients with chest trauma who have no detected fractures on radiography.

Trial of Injected Liposomal Bupivacaine vs Bupivacaine Infusion After Surgical Stabilization of Rib Fractures

ClinicalTrials.gov

2017-10-06

Drug Effect; Rib Fractures; Rib Trauma; Surgical Procedure, Unspecified; Pain; Catheter (Other); Nerve Pain; Local Infiltration; Anesthesia, Local; Intercostal Rib; Opioid Dependence; Chest Injury Trauma; Pneumonia

Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination?

PubMed

Soult, Michael C; Weireter, Leonard J; Britt, Rebecca C; Collins, Jay N; Novosel, Timothy J; Reed, Scott F; Britt, L D

2015-04-01

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

Emergency ultrasound in the acute assessment of haemothorax

PubMed Central

Brooks, A; Davies, B; Smethhurst, M; Connolly, J

2004-01-01

Aims: To evaluate thoracic ultrasound for the detection of haemothorax in patients with thoracic trauma against established investigations. Methods: Thoracic ultrasound was performed as an extension of the standard focused assessment with sonography for trauma (FAST) protocol used at the Queen's Medical Centre for the assessment of adult patients with torso trauma. Fluid was sought in both pleural cavities using a hand portable ultrasound system by one of two non-radiologists trained in FAST. Findings were compared against subsequent investigations/procedures performed at the discretion of the attending emergency physician—supine chest radiography, intercostal drain, computed tomography, or thoracotomy. The sensitivity of the technique and the time taken to diagnosis for each investigation were recorded. Results: Sixty one patients, 54 (89%) after blunt trauma, underwent thoracic ultrasound evaluation during the study. Twelve patients had a haemothorax detected by ultrasound and confirmed by computed tomography or by tube thoracostomy. Four haemothoraces detected on ultrasound were not apparent on trauma chest radiography. There were 12 true positives, 48 true negatives, no false positives, and one false negative scan. The sensitivity of ultrasound was 92% and specificity 100% with a positive predictive value of 100% and negative predictive value 98% for the detection of haemothorax after trauma. Conclusions: Emergency ultrasound of the chest performed as part of the primary survey of the traumatised patient can rapidly and accurately diagnose haemothorax and is a valuable tool to augment the immediate clinical assessment of these patients. PMID:14734374

Implementation of a CT Scan Practice Guideline for Pediatric Trauma Patients Reduces Unnecessary Scans Without Impacting Outcomes.

PubMed

McGrew, Patrick R; Chestovich, Paul J; Fisher, Jay D; Kuhls, Deborah A; Fraser, Douglas R; Patel, Purvi P; Katona, Chad W; Saquib, Syed; Fildes, John J

2018-05-04

Computed Tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the utility of CT scan guidelines in the management of pediatric trauma. This study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT utilization before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis utilizing published criteria from the Pediatric Emergency Care and Research Network (PECARN). There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age<15) trauma patients seen in our TC from 2010-2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay (LOS), readmissions, and mortality. Categorical and continuous variables were analyzed with Chi-square and Wilcoxon rank-sum tests, respectively. P<0.05 was considered significant. We identified 1934 patients: 1106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8% respectively (p<0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT utilization, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Level IV, Therapeutic Study.

Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review.

PubMed

Sawa, Jake; Green, Robert S; Thoma, Brent; Erdogan, Mete; Davis, Philip J

2017-08-11

The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma. EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes. Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured. While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

Impact of an open-chest extracorporeal membrane oxygenation model for in situ simulated team training: a pilot study.

PubMed

Atamanyuk, Iryna; Ghez, Olivier; Saeed, Imran; Lane, Mary; Hall, Judith; Jackson, Tim; Desai, Ajay; Burmester, Margarita

2014-01-01

To develop an affordable realistic open-chest extracorporeal membrane oxygenation (ECMO) model for embedded in situ interprofessional crisis resource management training in emergency management of a post-cardiac surgery child. An innovative attachment to a high-fidelity mannequin (Laerdal Simbaby) was used to enable a cardiac tamponade/ECMO standstill scenario. Two saline bags with blood dye were placed over the mannequin's chest. A 'heart' bag with venous and arterial outlets was connected to the corresponding tubes of the ECMO circuit. The bag was divided into arterial and venous parts by loosely wrapping silicon tubing around its centre. A 'pericardial' bag was placed above it. Both were then covered by a chest skin that had a sutured silicone membrane window. False blood injected into the 'pericardial' bag caused expansion leading to (i) bulging of silastic membrane, simulating tamponade, and (ii) compression of tubing around the 'heart' bag, creating negative venous pressures and cessation of ECMO flow. In situ Simulation Paediatric Resuscitation Team Training (SPRinT) was performed on paediatric intensive care unit; the course included a formal team training/scenario of an open-chest ECMO child with acute cardiac tamponade due to blocked chest drains/debriefing by trained facilitators. Cardiac tamponade was reproducible, and ECMO flow/circuit pressure changes were effective and appropriate. There were eight participants: one cardiac surgeon, two intensivists, one cardiologist, one perfusionist and three nurses. Five of the eight reported the realism of the model and 6/8 the realism of the clinical scenario as highly effective. Eight of eight reported a highly effective impact on (i) their practice and (ii) teamwork. Six of eight reported a highly effective impact on communication skills and increased confidence in attending future real events. Innovative adaptation of a high-fidelity mannequin for open-chest ECMO simulation can achieve a realistic and reproducible training model. The impact on interprofessional team training is promising but needs to be validated further.

Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria.

PubMed

Raja, Ali S; Mower, William R; Nishijima, Daniel K; Hendey, Gregory W; Baumann, Brigitte M; Medak, Anthony J; Rodriguez, Robert M

2016-08-01

The use of chest computed tomography (CT) to evaluate emergency department patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified "low risk." We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients. This was a secondary analysis of data on patients in the derivation and validation cohorts of the prospective, observational NEXUS Chest CT study, performed September 2011 to May 2014 in 11 Level I trauma centers. Institutional review board approval was obtained at all study sites. Adult blunt trauma patients receiving chest CT were included. The primary outcome was injury and major clinical injury prevalence and screening performance in patients with combinations of one, two, or three of seven individual NEXUS Chest CT criteria. Across the 11 study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median = 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] = 68.1 to 78.6) and specificity of 83.9 (95% CI = 83.6 to 84.2) for major clinical injury, abnormal chest-x-ray (CXR) was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalences were 60.7% (95% CI = 52.2% to 68.6%) and 12.9% (95% CI = 8.3% to 19.4%), respectively. Injury and major clinical injury prevalences when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI = 15.2% to 18.6%) and 1.1% (95% CI = 0.1% to 1.8%), respectively. Injury and major clinical injury prevalences among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI = 23.1% to 28.0%) and 3.2% (95% CI = 2.3% to 4.4%) and 34.9% (95% CI = 31.0% to 39.0%) and 2.7% (95% CI = 1.6% to 4.5%), respectively. We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria-chest CT may be indicated in cases requiring greater anatomic detail and injury characterization. © 2016 by the Society for Academic Emergency Medicine.

Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries).

PubMed

de Lesquen, Henri; Avaro, Jean-Philippe; Gust, Lucile; Ford, Robert Michael; Beranger, Fabien; Natale, Claudia; Bonnet, Pierre-Mathieu; D'Journo, Xavier-Benoît

2015-03-01

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective.

PubMed

Cowley, Alan; Durge, Neal

2014-05-13

Major trauma remains a significant cause of mortality and morbidity in young people and adolescents throughout the western world. Both the physical and psychological consequences of trauma are well documented and it is shown that peri-traumatic factors play a large part in the emotional recovery of children involved in trauma. Indeed, parental anxiety levels may play one of the biggest roles. There are no publically available guidelines on pre-hospital accompaniment, and where research has been done on parental presence it often focuses primarily on the parents or staff, rather than the child themselves. Whilst acknowledging the impact on parents and staff, the importance of the emotional wellbeing of the child should be reinforced, to reduce the likelihood of developing symptoms in keeping with post-traumatic stress disorder. This non-systematic literature review, aims to examine the impact of parental accompaniment to hospital, following paediatric trauma, and to help pre-hospital clinicians decide whether accompaniment would be of benefit to their patient population. The lack of published data does not enable a formal recommendation of parental accompaniment in the helicopter to be mandated, though it should be the preference in land based conveyance. Future research is needed into the emotional recovery of children after trauma, as well as the experiences of patient, parent and staff during conveyance.

The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective

PubMed Central

2014-01-01

Major trauma remains a significant cause of mortality and morbidity in young people and adolescents throughout the western world. Both the physical and psychological consequences of trauma are well documented and it is shown that peri-traumatic factors play a large part in the emotional recovery of children involved in trauma. Indeed, parental anxiety levels may play one of the biggest roles. There are no publically available guidelines on pre-hospital accompaniment, and where research has been done on parental presence it often focuses primarily on the parents or staff, rather than the child themselves. Whilst acknowledging the impact on parents and staff, the importance of the emotional wellbeing of the child should be reinforced, to reduce the likelihood of developing symptoms in keeping with post-traumatic stress disorder. This non-systematic literature review, aims to examine the impact of parental accompaniment to hospital, following paediatric trauma, and to help pre-hospital clinicians decide whether accompaniment would be of benefit to their patient population. The lack of published data does not enable a formal recommendation of parental accompaniment in the helicopter to be mandated, though it should be the preference in land based conveyance. Future research is needed into the emotional recovery of children after trauma, as well as the experiences of patient, parent and staff during conveyance. PMID:24887082

Isolated right atrial appendage rupture following blunt chest trauma.

PubMed

Hegde, Rakesh; Lafayette, Nathan; Sywak, Michael; Ricketts, Gregory; Otero, Jorge; Kurtzman, Scott; Zhang, Zhongqiu

2018-02-01

Right sided tears or rupture are the most common injury to the heart after blunt chest trauma. The majority of these injuries are to the thin walled atrium. Reports of localized right atrial appendage rupture are rare. The classical features of Beck's triad are unreliable in the trauma bay. With the advent of EFAST (Focused assessment with sonography for trauma extended to thorax), Beck's triad should be considered but not used as the primary clinical tool for diagnosis of cardiac tamponade [1]. EFAST aids in rapid diagnosis and definitive care [3]. Our patient was a 17 year old male who presented with hypotension after a rollover motor vehicle accident. He presented with a grossly negative physical exam and positive EFAST for pericardial effusion with tamponade physiology. We performed an emergency pericardiocentesis and expedited transportation for operative exploration. A Right atrial appendage injury was identified and repaired and patient recovered uneventfully. EFAST examination aids in rapid diagnosis of cardiac tamponade in the trauma setting. Pericardiocentesis facilitates temporizing the hemodynamics in preparation for operative exploration.

Chest injuries associated with earthquakes: an analysis of injuries sustained during the 2008 Wen-Chuan earthquake in China.

PubMed

Hu, Jia; Guo, Ying-Qiang; Zhang, Er-Yong; Tan, Jin; Shi, Ying-Kang

2010-08-01

The goal of this study was to analyze the patterns, therapeutic modalities, and short-term outcomes of patients with chest injuries in the aftermath of the Wen-Chuan earthquake, which occurred on May 12, 2008 and registered 8.0 on the Richter scale. Of the 1522 patients who were referred to the West China Hospital of Sichuan University from May 12 to May 27, 169 patients (11.1%) had suffered major chest injuries. The type of injury, the presence of infection, Abbreviated Injury Score (AIS 2005), New Injury Severity Score (NISS), treatment, and short-term outcome were all documented for each case. Isolated chest injuries were diagnosed in 129 patients (76.3%), while multiple injuries with a major chest trauma were diagnosed in 40 patients (23.7%). The mean AIS and the median NISS of the hospitalized patients with chest injuries were 2.5 and 13, respectively. The mortality rate was 3.0% (5 patients). Most of the chest injuries were classified as minor to moderate trauma; however, coexistent multiple injuries and subsequent infection should be carefully considered in medical response strategies. Coordinated efforts among emergency medical support groups and prior training in earthquake preparedness and rescue in earthquake-prone areas are therefore necessary for efficient evacuation and treatment of catastrophic casualties.

Prevention and recognition of abusive head trauma: training for healthcare professionals in Vietnam.

PubMed

Fraser, Jennifer A; Flemington, Tara; Doan, Thi Ngoc Diep; Hoang, Minh Tu Van; Doan, Thi Le Binh; Ha, Manh Tuan

2017-10-01

This study presents results from an intervention designed to improve identification and response to abusive head trauma in a tertiary paediatric hospital in Vietnam. One hundred and sixteen healthcare professionals (paediatric medical and nursing staff) completed a clinical training programme and participated in its evaluation. A pre-post-test and follow-up design was used to evaluate the outcomes. Questionnaires were used to collect data prior to training, at six weeks and at six months. Generalised linear modelling was used to examine changes in diagnostic skills and knowledge of the consequences of shaken baby syndrome (SBS) (a form of abusive head trauma), its prevention and treatment. At baseline, awareness and knowledge reflected no former abusive head trauma training. Following the intervention, participants had an increased awareness of shaken baby syndrome and the potential consequences of shaking infants and had acquired techniques to inform parents how to manage the crying infant. The intervention was effective in raising awareness of shaken baby syndrome and its consequences amongst the participating healthcare professionals in Vietnam. Training can improve detection and prevention of abusive head trauma, and the intervention has the potential to be adapted for similar settings internationally. ©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

Combined Tricuspid Valvuloplasty and Superior Cavopulmonary Anastomosis for Repair of Traumatic Tricuspid Valve Injury

PubMed Central

Dimas, V. Vivian; Grifka, Ronald G.; Fraser, Charles D.

2004-01-01

Chronic tricuspid valve insufficiency secondary to blunt chest trauma is rare in the pediatric population, with fewer than 10 cases reported. Surgical repair has focused on the tricuspid valve. We present 2 cases of traumatic tricuspid valve insufficiency in pediatric patients after blunt chest trauma in whom tricuspid valve repair was performed along with superior cavopulmonary anastomosis. To our knowledge, this is the 1st report of the use of this combination of surgical procedures for repair of traumatic tricuspid regurgitation in either adults or children. PMID:15745295

Factors determining outcome of corrective osteotomy for malunited paediatric forearm fractures: a systematic review and meta-analysis

PubMed Central

Roth, K. C.; Walenkamp, M. M. J.; van Geenen, R. C. I.; Reijman, M.; Verhaar, J. A. N.; Colaris, J. W.

2017-01-01

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques. Level of evidence: II PMID:28891765

Blunt chest trauma--an audit of injuries diagnosed by the MDCT examination.

PubMed

Turkalj, Ivan; Petrović, Kosta; Stojanović, Sanja; Petrović, Djordje; Brakus, Alma; Ristić, Jelena

2014-02-01

Multidetector computed tomography (MDCT) characterised by speed and precision is increasingly accessible in emergency wards. The aim of our study was to determine the most common injuries to the chest region, as well as type associated extrathoracic injuries, and the treatment outcome. This prospective study included 61 patients with blunt trauma who were submitted to computed tomography (CT) of the thorax. The number of injuries was evaluated by organs and organ systems of the chest. The cause of the injury, the length and the outcome of the treatment, and the presence of injuries in other regions were assessed. Chest injuries were associated with injuries to other regions in 80.3% cases, predominantly injuries to extremities or pelvic bones in 54.1% cases, followed by head injuries in 39.3% patients. Associated thoracic injuries were present in 90.9% of patients with lethal outcome. Lung parenchymal lesions, pleural effusions and rib fractures were the most common injuries affecting 77.1%, 65.6% and 63.9% of the cases, respectively. Blunt chest trauma is a significant problem affecting predominantly males in their forties and it is usually caused by a motor vehicle accident. In case of pneumomediastinum or mediastinal haematoma, the use of 3D reconstructions is advised for diagnosing possible tracheobronchial ruptures and thoracic aorta injuries. Increased resolution of CT scanners yielded a large number of findings that are occult on radiography, especially in the event of lung parenchymal and pleural injuries. However, none imaging modality can replace surgical judgement.

Dose evaluation in paediatric patients undergoing chest X-ray examinations

NASA Astrophysics Data System (ADS)

Piantini, F.; Schelin, H. R.; Denyak, V.; Bunick, A. P.; Legnani, A.; Ledesma, J. A.; Filipov, D.; Paschuk, S. A.

2017-11-01

This study aimed to estimate the incident air kerma in chest X-ray examinations, for lateral (LAT) and anterior-posterior (AP) (together with posterior-anterior (PA)) projections, in one of the largest paediatric hospitals in Brazil, and to compare these with the results obtained in a general hospital of the same city. The dosimetric results were analysed along with the patient characteristics and radiographer strategies. The examinations of 225 (119 male and 106 female) patients were studied and 389 X-ray scans (200 AP/PA projections and 189 LAT projections) of paediatric patients were acquired. For analysis of the results, the patients were divided into the following age groups: 0-1 y, 1-5 y, 5-10 y, and 10-15 y. Patient's thickness can be determined from age, height or weight with an uncertainty of 20-30%. In different hospitals, the difference in patient's thicknesses between the same age groups can reach 25-55%. A minimal correlation between the patient dose and thickness was observed, with a 4-fold difference in the dose for patients of the same thickness. By standardizing radiological protocols, it should be possible to keep the dose within intervals of 50-100 μGy for LAT projection and 40-80 μGy for AP/PA projection.

Cardiac Trauma.

PubMed

Gosavi, Sucheta; Tyroch, Alan H; Mukherjee, Debabrata

2016-11-01

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Computed Tomographic Findings and Mortality in Patients With Pneumomediastinum From Blunt Trauma.

PubMed

Lee, Wayne S; Chong, Vincent E; Victorino, Gregory P

2015-08-01

The care of most patients with pneumomediastinum (PNM) due to trauma can be managed conservatively; however, owing to aerodigestive tract injury and other associated injuries, there is a subset of patients with PNM who are at higher risk of mortality but can be difficult to identify. To characterize computed tomographic (CT) findings associated with mortality in patients with PNM due to blunt trauma. A retrospective review of medical records from January 1, 2002, to December 31, 2011, was conducted at a university-based urban trauma center. The patients evaluated were those injured by blunt trauma and found to have PNM on initial chest CT scanning. Data analysis was performed July 2, 2013, to June 18, 2014. In-hospital mortality. During the study period, 3327 patients with blunt trauma underwent chest CT. Of these, 72 patients (2.2%) had PNM. Patients with PNM had higher Injury Severity Scores (P < .001) and chest Abbreviated Injury Scale scores (P < .001) compared with those without PNM. Pneumomediastinum was associated with higher mortality (9 [12.5%] vs 118 [3.6%] patients; P < .001) and longer mean (SD) hospital stays (11.3 [14.6] vs 5.1 [8.8] days; P < .001), intensive care unit stays (5.4 [10.2] vs 1.8 [5.7] days; P < .001), and ventilator days (1.7 [4.2] vs 0.6 [4.0] days; P < .03). We evaluated several chest CT findings that may have predictive value. Pneumomediastinum size was not associated with in-hospital mortality (P = .22). However, location of air in the posterior mediastinum was associated with increased mortality of 25% (7 of 28 patients; P = .007). Air in all mediastinal compartments was also associated with increased mortality of 40.0% (4 of 10 patients; P = .01). Presence of hemothorax along with PNM was associated with mortality of 22.2% (8 of 36 patients; P = .01). Pneumomediastinum is uncommon in patients with injury from blunt trauma; however, CT findings of posterior PNM, air in all mediastinal compartments, and concurrent hemothorax are associated with increased mortality. These CT findings could be used as a triage tool to alert the trauma surgeon to a potentially lethal injury.

Can handheld micropower impulse radar technology be used to detect pneumothorax? Initial experience in a European trauma centre.

PubMed

Albers, C E; Haefeli, P C; Zimmermann, H; de Moya, M; Exadaktylos, A K

2013-05-01

Pneumothoraces are a common injury pattern in emergency medicine. Rapid and safe identification can reduce morbidity and mortality. A new handheld, battery powered device, the Pneumoscan (CE 561036, PneumoSonics Inc., Cleveland, OH, USA), using micropower impulse radar (MIR) technology, has recently been introduced in Europe for the rapid and reliable detection of PTX. However, this technology has not yet been tested in trauma patients. This is the first quality control evaluation to report on emergency room performance of a new device used in the trauma setting. This study was performed at a Level I trauma centre in Switzerland. All patients with thoracic trauma and undergoing chest X-ray and CT-scan were eligible for the study. Readings were performed before the chest X-ray and CT scan. The patients had eight lung fields tested (four on each side). All readings with the Pneumoscan were performed by two junior residents in our department who had previously received an instructional tutorial of 15min. The qualitative MIR results were blinded, and stored on the device. We then compared the results of the MIR to those of the clinical examination, chest X-ray and CT-scan. 50 patients were included, with a mean age of 46 (SD 17) years. Seven patients presented with PTX diagnosed by CT; six of these were detected by Pneumoscan, leading to an overall sensitivity of 85.7 (95% confidence interval 42.1-99.6)%. Only two of seven PTX were found during clinical examination and on chest X-ray (sensitivity 28.6 (95% CI 3.7-71.0)%). Of the remaining 43 of 50 patients without PTX, one false-positive PTX was found by the Pneumoscan, resulting in a specificity of 97.7 (95% CI 87.7-99.9)%. The Pneumoscan is an easy to use handheld technology with reliable results. In this series, the sensitivity to detect a PTX by the Pneumoscan was higher than by clinical examination and chest X-ray. Further studies with higher case numbers and a prospective study design are needed to confirm our findings. Copyright © 2012 Elsevier Ltd. All rights reserved.

CT dose reduction using Automatic Exposure Control and iterative reconstruction: A chest paediatric phantoms study.

PubMed

Greffier, Joël; Pereira, Fabricio; Macri, Francesco; Beregi, Jean-Paul; Larbi, Ahmed

2016-04-01

To evaluate the impact of Automatic Exposure Control (AEC) on radiation dose and image quality in paediatric chest scans (MDCT), with or without iterative reconstruction (IR). Three anthropomorphic phantoms representing children aged one, five and 10-year-old were explored using AEC system (CARE Dose 4D) with five modulation strength options. For each phantom, six acquisitions were carried out: one with fixed mAs (without AEC) and five each with different modulation strength. Raw data were reconstructed with Filtered Back Projection (FBP) and with two distinct levels of IR using soft and strong kernels. Dose reduction and image quality indices (Noise, SNR, CNR) were measured in lung and soft tissues. Noise Power Spectrum (NPS) was evaluated with a Catphan 600 phantom. The use of AEC produced a significant dose reduction (p<0.01) for all anthropomorphic sizes employed. According to the modulation strength applied, dose delivered was reduced from 43% to 91%. This pattern led to significantly increased noise (p<0.01) and reduced SNR and CNR (p<0.01). However, IR was able to improve these indices. The use of AEC/IR preserved image quality indices with a lower dose delivered. Doses were reduced from 39% to 58% for the one-year-old phantom, from 46% to 63% for the five-year-old phantom, and from 58% to 74% for the 10-year-old phantom. In addition, AEC/IR changed the patterns of NPS curves in amplitude and in spatial frequency. In chest paediatric MDCT, the use of AEC with IR allows one to obtain a significant dose reduction while maintaining constant image quality indices. Copyright © 2016 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.

Is chest x-ray an adequate screening tool for the diagnosis of blunt thoracic aortic injury?

PubMed

Ekeh, Akpofure Peter; Peterson, Wylan; Woods, Randy J; Walusimbi, Mbaga; Nwuneli, Nancy; Saxe, Jonathan M; McCarthy, Mary C

2008-11-01

Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI. All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI. In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001. Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Blunt gastric injuries.

PubMed

Oncel, Didem; Malinoski, Darren; Brown, Carlos; Demetriades, Demetrios; Salim, Ali

2007-09-01

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.

Pediatric Thoracic Trauma: Recognition and Management.

PubMed

Reynolds, Stacy L

2018-05-01

Thoracic injuries account for less than one-tenth of all pediatric trauma-related injuries but comprise 14% of pediatric trauma-related deaths. Thoracic trauma includes injuries to the lungs, heart, aorta and great vessels, esophagus, tracheobronchial tree, and structures of the chest wall. Children have unique anatomic features that change the patterns of observed injury compared with adults. This review article outlines the clinical presentation, diagnostic testing, and management principles required to successfully manage injured children with thoracic trauma. Copyright © 2018 Elsevier Inc. All rights reserved.

Average chest wall thickness at two anatomic locations in trauma patients.

PubMed

Schroeder, Elizabeth; Valdez, Carrie; Krauthamer, Andres; Khati, Nadia; Rasmus, Jessica; Amdur, Richard; Brindle, Kathleen; Sarani, Babak

2013-09-01

Needle thoracostomy is the emergent treatment for tension pneumothorax. This procedure is commonly done using a 4.5cm catheter, and the optimal site for chest wall puncture is controversial. We hypothesize that needle thoracostomy cannot be performed using this catheter length irrespective of the site chosen in either gender. A retrospective review of all chest computed tomography (CT) scans obtained on trauma patients from January 1, 2011 to December 31, 2011 was performed. Patients aged 18 and 80 years were included and patients whose chest wall thickness exceeded the boundary of the images acquired were excluded. Chest wall thickness was measured at the 2nd intercostal (ICS), midclavicular line (MCL) and the 5th ICS, anterior axillary line (AAL). Injury severity score (ISS), chest wall thickness, and body mass index (BMI) were analyzed. 201 patients were included, 54% male. Average (SD) BMI was 26 (7)kg/m(2). The average chest wall thickness in the overall cohort was 4.08 (1.4)cm at the 2nd ICS/MCL and 4.55 (1.7)cm at the 5th ICS/AAL. 29% of the overall cohort (27 male and 32 female) had a chest wall thickness greater than 4.5cm at the 2nd ICS/MCL and 45% (54 male and 36 female) had a chest wall thickness greater than 4.5cm at the 5th ICS/AAL. There was no significant interaction between gender and chest wall thickness at either site. BMI was positively associated with chest wall thickness at both the 2nd and 5th ICS/AAL. A 4.5cm catheter is inadequate for needle thoracostomy in most patients regardless of puncture site or gender. Copyright © 2013 Elsevier Ltd. All rights reserved.

Thoracic wall trauma—misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging

PubMed Central

Facenda, Catherine; Vaz, Nuno; Castañeda, Edgar Augusto; del Amo, Montserrat; Garcia-Diez, Ana Isabel; Pomes, Jaime

2017-01-01

Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the “gold-standard” for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way. PMID:28932697

Minimally displaced clavicle fracture after high-energy injury: are they likely to displace?

PubMed

Riehl, John T; Athans, Bill J; Munro, Mark W; Langford, Joshua R; Kupiszewski, Stanley J; Haidukewych, George J; Koval, Kenneth J

2014-06-01

Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture. We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded. Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission. Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.

Minimally displaced clavicle fracture after high-energy injury: Are they likely to displace?

PubMed Central

Riehl, John T.; Athans, Bill J.; Munro, Mark W.; Langford, Joshua R.; Kupiszewski, Stanley J.; Haidukewych, George J.; Koval, Kenneth J.

2014-01-01

Background Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture. Methods We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded. Results Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission. Conclusion Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury. PMID:24869608

Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments.

PubMed

Calderon, Georgina; Perez, Daniel; Fortman, Jonathan; Kea, Bory; Rodriguez, Robert M

2012-10-01

Although they infrequently lead to management changing diagnoses, chest x-rays (CXRs) are the most commonly ordered imaging study in blunt trauma evaluation. To determine: 1) the reasons physicians order chest X-ray studies (CXRs) in blunt trauma assessments; 2) what injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low likelihood of injury on CXR. At a Level I Trauma Center, we asked resident and attending physicians treating adult blunt trauma patients: 1) the primary reason(s) for getting CXRs; 2) what, if any, significant intrathoracic injuries (SITI) they expected CXRs to reveal; and 3) the likelihood of these injuries. An expert panel defined SITI as two or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings. There were 484 patient encounters analyzed--65% of participating physicians were residents and 35% were attendings; 16 (3.3%) patients had SITI. The most common reasons for ordering CXRs were: "enough concern for significant injury" (62.9%) and belief that CXR is a "standard part of trauma work-up" (24.8%). Residents were more likely than attendings to cite "standard trauma work-up" (mean difference = 13.5%, p = 0.003). When physicians estimated a < 10% likelihood of SITI on CXR, 2.1% (95% confidence interval [CI] 1.0-4.1%) of patients had SITI; when they predicted a 10-25% likelihood, 5.7% (95% CI 1.2-15.7%) had SITI; and when they predicted a > 25% likelihood, 9.1% (95% CI 3.0-20.0%) had SITI. Physicians order CXRs in blunt trauma patients because they expect to find injuries and believe that CXRs are part of a "standard" work-up. Providers commonly do not expect CXRs to reveal SITI. When providers estimated low likelihood of SITI, the rate of SITI was very low. Published by Elsevier Inc.

Retrospective Cohort Analysis of Chest Injury Characteristics and Concurrent Injuries in Patients Admitted to Hospital in the Wenchuan and Lushan Earthquakes in Sichuan, China

PubMed Central

Yuan, Yong; Zhao, Yong-Fan

2014-01-01

Background The aim of this study was to compare retrospectively the characteristics of chest injuries and frequencies of other, concurrent injuries in patients after earthquakes of different seismic intensity. Methods We compared the cause, type, and body location of chest injuries as well as the frequencies of other, concurrent injuries in patients admitted to our hospital after the Wenchuan and Lushan earthquakes in Sichuan, China. We explored possible relationships between seismic intensity and the causes and types of injuries, and we assessed the ability of the Injury Severity Score, New Injury Severity Score, and Chest Injury Index to predict respiratory failure in chest injury patients. Results The incidence of chest injuries was 9.9% in the stronger Wenchuan earthquake and 22.2% in the less intensive Lushan earthquake. The most frequent cause of chest injuries in both earthquakes was being accidentally struck. Injuries due to falls were less prevalent in the stronger Wenchuan earthquake, while injuries due to burial were more prevalent. The distribution of types of chest injury did not vary significantly between the two earthquakes, with rib fractures and pulmonary contusions the most frequent types. Spinal and head injuries concurrent with chest injuries were more prevalent in the less violent Lushan earthquake. All three trauma scoring systems showed poor ability to predict respiratory failure in patients with earthquake-related chest injuries. Conclusions Previous studies may have underestimated the incidence of chest injury in violent earthquakes. The distributions of types of chest injury did not differ between these two earthquakes of different seismic intensity. Earthquake severity and interval between rescue and treatment may influence the prevalence and types of injuries that co-occur with the chest injury. Trauma evaluation scores on their own are inadequate predictors of respiratory failure in patients with earthquake-related chest injuries. PMID:24816485

Retrospective cohort analysis of chest injury characteristics and concurrent injuries in patients admitted to hospital in the Wenchuan and Lushan earthquakes in Sichuan, China.

PubMed

Zheng, Xi; Hu, Yang; Yuan, Yong; Zhao, Yong-Fan

2014-01-01

The aim of this study was to compare retrospectively the characteristics of chest injuries and frequencies of other, concurrent injuries in patients after earthquakes of different seismic intensity. We compared the cause, type, and body location of chest injuries as well as the frequencies of other, concurrent injuries in patients admitted to our hospital after the Wenchuan and Lushan earthquakes in Sichuan, China. We explored possible relationships between seismic intensity and the causes and types of injuries, and we assessed the ability of the Injury Severity Score, New Injury Severity Score, and Chest Injury Index to predict respiratory failure in chest injury patients. The incidence of chest injuries was 9.9% in the stronger Wenchuan earthquake and 22.2% in the less intensive Lushan earthquake. The most frequent cause of chest injuries in both earthquakes was being accidentally struck. Injuries due to falls were less prevalent in the stronger Wenchuan earthquake, while injuries due to burial were more prevalent. The distribution of types of chest injury did not vary significantly between the two earthquakes, with rib fractures and pulmonary contusions the most frequent types. Spinal and head injuries concurrent with chest injuries were more prevalent in the less violent Lushan earthquake. All three trauma scoring systems showed poor ability to predict respiratory failure in patients with earthquake-related chest injuries. Previous studies may have underestimated the incidence of chest injury in violent earthquakes. The distributions of types of chest injury did not differ between these two earthquakes of different seismic intensity. Earthquake severity and interval between rescue and treatment may influence the prevalence and types of injuries that co-occur with the chest injury. Trauma evaluation scores on their own are inadequate predictors of respiratory failure in patients with earthquake-related chest injuries.

Focused abdominal sonography for trauma (FAST) in blunt paediatric abdominal trauma.

PubMed

Faruque, Ahmad Vaqas; Qazi, Saqib Hamid; Khan, Muhammad Arif Mateen; Akhtar, Wassem; Majeed, Amina

2013-03-01

To evaluate the role of focussed abdominal sonography for trauma in blunt paediatric abdominal trauma patients, and to see if the role of computed tomography scan could be limited to only those cases in which sonography was positive. The retrospective study covered 10 years, from January 1,2000 to December 31,2009, and was conducted at the Department of Radiology and Department of Emergency Medicine, Aga Khan University Hospital, Karachi. It comprised cases of 174 children from birth to 14 years who had presented with blunt abdominal trauma and had focussed abdominal sonography for trauma done at the hospital. The findings were correlated with computed tomography scan of the abdomen and clinical follow-up. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of focussed abdominal sonography for trauma were calculated for blunt abdominal trauma. SPSS 17 was used for statistical analysis. Of the total 174 cases, 31 (17.81%) were later confirmed by abdominal scan. Of these 31 children, sonography had been positive in 29 (93.54%) children. In 21 (67.74%) of the 31 children, sonograpy had been true positive; 8 (25%) (8/31) were false positive; and 2 (6%) (2/31) were false negative. There were 6 (19.3%) children in which sonography was positive and converted to laparotomy. There was no significant difference on account of gender (p>0.356). Focussed abdominal sonography for trauma in the study had sensitivity of 91%, specificity of 95%, positive predictive value of 73%, and negative predictive value of 73% with accuracy of 94%. All patients who had negative sonography were discharged later, and had no complication on clinical follow-up. Focussed abdominal sonography for trauma is a fairly reliable mode to assess blunt abdominal trauma in children. It is a useful tool to pick high-grade solid and hollow viscous injury. The results suggest that the role of computed tomography scan can be limited to those cases in which focussed sonography is positive.

14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small?

PubMed

Kulvatunyou, Narong; Joseph, Bellal; Friese, Randall S; Green, Donald; Gries, Lynn; O'Keeffe, Terence; Tang, Andy L; Wynne, Julie L; Rhee, Peter

2012-12-01

Small 14F pigtail catheters (PCs) have been shown to drain air quite well in patients with traumatic pneumothorax (PTX). But their effectiveness in draining blood in patients with traumatic hemothorax (HTX) or hemopneumothorax (HPTX) is unknown. We hypothesized that 14F PCs can drain blood as well as large-bore 32F to 40F chest tubes. We herein report our early case series experience with PCs in the management of traumatic HTX and HPTX. We prospectively collected data on all bedside-inserted PCs in patients with traumatic HTX or HPTX during a 30-month period (July 2009 through December 2011) at our Level I trauma center. We then compared our PC prospective data with our trauma registry-derived retrospective chest tube data (January 2008 through December 2010) at our center. Our primary outcome of interest was the initial drainage output. Our secondary outcomes were tube duration, insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t-test, χ test, and Wilcoxon rank-sum test; we defined significance by a value of p < 0.05. A total of 36 patients received PCs, and 191 received chest tubes. Our PC group had a higher rate of blunt mechanism injuries than our chest tube group did (83 vs. 62%; p = 0.01). The mean initial output was similar between our PC group (560 ± 81 mL) and our chest tube group (426 ± 37 mL) (p = 0.13). In the PC group, the tube was inserted later (median, Day 1; interquartile range, Days 0-3) than the tube inserted in our chest tube group (median, Day 0; interquartile range, Days 0-0) (p < 0.001). Tube duration, rate of insertion-related complications, and failure rate were all similar. In our early experience, 14F PCs seemed to drain blood as well as large-bore chest tubes based on initial drainage output and other outcomes studied. In this early phase, we were being selective in inserting PCs in only stable blunt trauma patients, and PCs were inserted at a later day from the time of the initial evaluation. In the future, we will need a larger sample size and possibly a well-designed prospective study. Therapeutic study, level V.

The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy.

PubMed

de Abreu, Emanuelle Maria Sávio; Machado, Carla Jorge; Pastore Neto, Mario; de Rezende Neto, João Baptista; Sanches, Marcelo Dias

2015-01-01

to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention. A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes. Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias. Implementation of a TTP effectively reduced complications after CTT in trauma patients.

Thoracic injury rule out criteria and NEXUS chest in predicting the risk of traumatic intra-thoracic injuries: A diagnostic accuracy study.

PubMed

Safari, Saeed; Radfar, Fatemeh; Baratloo, Alireza

2018-05-01

This study aimed to compare the diagnostic accuracy of NEXUS chest and Thoracic Injury Rule out criteria (TIRC) models in predicting the risk of intra-thoracic injuries following blunt multiple trauma. In this diagnostic accuracy study, using the 2 mentioned models, blunt multiple trauma patients over the age of 15 years presenting to emergency department were screened regarding the presence of intra-thoracic injuries that are detectable via chest x-ray and screening performance characteristics of the models were compared. In this study, 3118 patients with the mean (SD) age of 37.4 (16.9) years were studied (57.4% male). Based on TIRC and NEXUS chest, respectively, 1340 (43%) and 1417 (45.4%) patients were deemed in need of radiography performance. Sensitivity, specificity, and positive and negative predictive values of TIRC were 98.95%, 62.70%, 21.19% and 99.83%. These values were 98.61%, 59.94%, 19.97% and 99.76%, for NEXUS chest, respectively. Accuracy of TIRC and NEXUS chest models were 66.04 (95% CI: 64.34-67.70) and 63.50 (95% CI: 61.78-65.19), respectively. TIRC and NEXUS chest models have proper and similar sensitivity in prediction of blunt traumatic intra-thoracic injuries that are detectable via chest x-ray. However, TIRC had a significantly higher specificity in this regard. Copyright © 2018 Elsevier Ltd. All rights reserved.

Clinician's gaze behaviour in simulated paediatric emergencies.

PubMed

McNaughten, Ben; Hart, Caroline; Gallagher, Stephen; Junk, Carol; Coulter, Patricia; Thompson, Andrew; Bourke, Thomas

2018-03-07

Differences in the gaze behaviour of experts and novices are described in aviation and surgery. This study sought to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency. Clinicians from four clinical areas undertook a simulated emergency. Participants wore SMI (SensoMotoric Instruments) eye tracking glasses. We measured the fixation count and dwell time on predefined areas of interest and the time taken to key clinical interventions. Paediatric intensive care unit (PICU) consultants performed best and focused longer on the chest and airway. Paediatric consultants and trainees spent longer looking at the defibrillator and algorithm (51 180 ms and 50 551 ms, respectively) than the PICU and paediatric emergency medicine consultants. This study is the first to describe differences in the gaze behaviour between experts and novices in a resuscitation. They mirror those described in aviation and surgery. Further research is needed to evaluate the potential use of eye tracking as an educational tool. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Misclassification of acute respiratory distress syndrome after traumatic injury: The cost of less rigorous approaches.

PubMed

Hendrickson, Carolyn M; Dobbins, Sarah; Redick, Brittney J; Greenberg, Molly D; Calfee, Carolyn S; Cohen, Mitchell Jay

2015-09-01

Adherence to rigorous research protocols for identifying adult respiratory distress syndrome (ARDS) after trauma is variable. To examine how misclassification of ARDS may bias observational studies in trauma populations, we evaluated the agreement of two methods for adjudicating ARDS after trauma: the current gold standard, direct review of chest radiographs and review of dictated radiology reports, a commonly used alternative. This nested cohort study included 123 mechanically ventilated patients between 2005 and 2008, with at least one PaO2/FIO2 less than 300 within the first 8 days of admission. Two blinded physician investigators adjudicated ARDS by two methods. The investigators directly reviewed all chest radiographs to evaluate for bilateral infiltrates. Several months later, blinded to their previous assessments, they adjudicated ARDS using a standardized rubric to classify radiology reports. A κ statistics was calculated. Regression analyses quantified the association between established risk factors as well as important clinical outcomes and ARDS determined by the aforementioned methods as well as hypoxemia as a surrogate marker. The κ was 0.47 for the observed agreement between ARDS adjudicated by direct review of chest radiographs and ARDS adjudicated by review of radiology reports. Both the magnitude and direction of bias on the estimates of association between ARDS and established risk factors as well as clinical outcomes varied by method of adjudication. Classification of ARDS by review of dictated radiology reports had only moderate agreement with the current gold standard, ARDS adjudicated by direct review of chest radiographs. While the misclassification of ARDS had varied effects on the estimates of associations with established risk factors, it tended to weaken the association of ARDS with important clinical outcomes. A standardized approach to ARDS adjudication after trauma by direct review of chest radiographs will minimize misclassification bias in future observational studies. Diagnostic study, level II.

No air leak on PPV does not exclude tracheobronchial injury after blunt chest trauma.

PubMed

Ong, Victor Yeok Kein; Tan, Kenneth Hock Soon

2008-04-01

Tracheobronchial injuries are commonly associated with persistent air leak with pneumothoraces especially when on positive pressure ventilation (PPV). Injuries with absence of these features together with collapse of the lung and consequent low arterial oxygen tension while on PPV are less well recognised. We present a patient with traumatic aortic dissection and preoperatively undiagnosed complete transaction of the left main bronchus following blunt chest trauma. He had no persistent air leak with lower lung lobe collapse despite undergoing PPV and had low arterial oxygen tension which failed to respond to appropriate oxygen therapy.

Rib Radiography versus Chest Computed Tomography in the Diagnosis of Rib Fractures.

PubMed

Sano, Atsushi

2018-05-01

 The accurate diagnosis of rib fractures is important in chest trauma. Diagnostic images following chest trauma are usually obtained via chest X-ray, chest computed tomography, or rib radiography. This study evaluated the diagnostic characteristics of rib radiography and chest computed tomography.  Seventy-five rib fracture patients who underwent both chest computed tomography and rib radiography between April 2008 and December 2013 were included. Rib radiographs, centered on the site of pain, were taken from two directions. Chest computed tomography was performed using a 16-row multidetector scanner with 5-mm slice-pitch without overlap, and axial images were visualized in a bone window.  In total, 217 rib fractures were diagnosed in 75 patients. Rib radiography missed 43 rib fractures in 24 patients. The causes were overlap with organs in 15 cases, trivial fractures in 21 cases, and injury outside the imaging range in 7 cases. Left lower rib fractures were often missed due to overlap with the heart, while middle and lower rib fractures were frequently not diagnosed due to overlap with abdominal organs. Computed tomography missed 21 rib fractures in 17 patients. The causes were horizontal fractures in 10 cases, trivial fractures in 9 cases, and insufficient breath holding in 1 case.  In rib radiography, overlap with organs and fractures outside the imaging range were characteristic reasons for missed diagnoses. In chest computed tomography, horizontal rib fractures and insufficient breath holding were often responsible. We should take these challenges into account when diagnosing rib fractures. Georg Thieme Verlag KG Stuttgart · New York.

Changing pattern and outcome of pediatric chest injuries in urban Syria.

PubMed

Darwish, Bassam; Mahfouz, Mohammad Z; Al-Nosairat, Saeed; Izzat, Mohammad Bashar

2018-01-01

Background Pediatric chest injuries were infrequent in our practice, but the outbreak of the Syrian crisis resulted in an increase in number and a change in the pattern of thoracic trauma incidents. We compared our experience of pediatric chest injuries before and during the crisis. Methods We reviewed the records of 256 children aged 12.8 ± 5 years who were admitted to our hospital with the diagnosis of chest trauma over a 12-year period. Collected data included mechanism of injury, associated injuries, method of management, length of hospital stay, complications, and mortality. Results The incidence of pediatric chest injuries increased significantly following the outbreak of the crisis, and penetrating injuries prevailed, mainly due to shrapnel, bullets, and stab wounds. Forty percent of patients with blunt injuries and 20% of those with penetrating injuries were managed conservatively, whereas urgent thoracotomies were indicated in 10%, mostly in patients with penetrating injuries. Associated injuries were more frequent in patients with blunt injuries and resulted in a longer hospital stay and an increased mortality rate. The overall mortality rate was 7.8% and it was higher in children younger than 7 years of age and in patients who had been subjected to blunt injuries. Conclusions There has been a recent substantial upsurge in the incidence of pediatric thoracic trauma, with a predominance of penetrating injuries. Most patients could be managed nonoperatively, but a small subset required an open thoracotomy. The presence of associated injuries constitutes the main determinant of prognosis in this group of patients.

Prevalence of large and occult pneumothoraces in patients with severe blunt trauma upon hospital admission: experience of 526 cases in a French level 1 trauma center.

PubMed

Charbit, Jonathan; Millet, Ingrid; Maury, Camille; Conte, Benjamin; Roustan, Jean-Paul; Taourel, Patrice; Capdevila, Xavier

2015-06-01

Occult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation. Patients with severe trauma consecutively admitted to our institution for 5 years were retrospectively analyzed. All patients with blunt thoracic trauma who had undergone computed tomographic (CT) within the first hour of hospitalization were included. Mechanical ventilation was considered as early if it was introduced in the prehospital period or on arrival at the hospital. Occult PTXs were defined as PTXs not visible on chest x-ray. All PTXs were measured on CT scan (largest thickness and vertical dimension). Large occult PTXs were defined by a largest thickness of 30 mm or more. Of the 526 patients studied, 395 (75%) were male, mean age was 37.9 years, mean Injury Severity Score was 22.2, and 247 (47%) received early mechanical ventilation. Of 429 diagnosed PTXs, 296 (69%) were occult. The proportion of occult PTXs classified as large was 11% (95% confidence interval, 8%-15%). The overall prevalence of large occult PTXs was 6% (95% confidence interval, 4%-8%). Both CT measurements and proportion of large occult PTXs were found statistically comparable in patients with or without mechanical ventilation. Six percent of studied patients with severe trauma had a large and occult PTX as soon as admission despite a normal chest x-ray result. The observed sizes and rates of occult PTX were comparable regardless of the initiation of early mechanical ventilation. Copyright © 2015. Published by Elsevier Inc.

Chest wall stabilization in trauma patients: why, when, and how?

PubMed Central

White, Thomas W.

2018-01-01

Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion’s role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available. PMID:29744222

Annual Trauma Anesthesia and Critical Care Symposium (5th) Held in Amsterdam, The Netherlands on 11-12 June 1992

DTIC Science & Technology

1992-10-01

Variations in the Role of the TA/CCS A. The Trauma Team: Leader vs. Member B. Pain Management C. Teacher/Trainer D. Critical Care Transport E... Pain Management Interested individuals should send CV and request for application to: David P. Tarantino, M.D. Director of Education MIEMSS...Supportive Treatment Strategy? Interpleural Regional Analgesia in the Pain Management of Chest Trauma Airway Management with Penetrating Neck Trauma

Acute refractory hypoxemia after chest trauma reversed by high-frequency oscillatory ventilation: a case report

PubMed Central

2013-01-01

Introduction Polytrauma often results in significant hypoxemia secondary to direct lung contusion or indirectly through atelectasis, systemic inflammatory response, large volume fluid resuscitation and blood product transfusion. In addition to causing hypoxemia, atelectasis and acute lung injury can lead to right ventricular failure through an acute increase in pulmonary vascular resistance. Mechanical ventilation is often applied, accompanied with recruitment maneuvers and positive end-expiratory pressure in order to recruit alveoli and reverse atelectasis, while preventing excessive alveolar damage. This strategy should lead to the reversal of the hypoxemic condition and the detrimental heart–lung interaction that may occur. However, as described in this case report, hemodynamic instability and intractable alveolar atelectasis sometimes do not respond to conventional ventilation strategies. Case presentation We describe the case of a 21-year-old Caucasian man with severe chest trauma requiring surgical interventions, who developed refractory hypoxemia and overt right ventricular failure. After multiple failed attempts of recruitment using conventional ventilation, the patient was ventilated with high-frequency oscillatory ventilation. This mode of ventilation allowed the reversal of the hemodynamic effects of severe hypoxemia and of the acute cor pulmonale. We use this case report to describe the physiological advantages of high-frequency oscillatory ventilation in patients with chest trauma, and formulate the arguments to explain the positive effect observed in our patient. Conclusions High-frequency oscillatory ventilation can be used in the context of a blunt chest trauma accompanied by severe hypoxemia due to atelectasis. The positive effect is due to its capacity to recruit the collapsed alveoli and, as a result, the relief of increased pulmonary vascular resistance and subsequently the reversal of acute cor pulmonale. This approach may represent an alternative in case of failure of the conventional ventilation strategy. PMID:23855954

Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma.

PubMed Central

Chirillo, F.; Totis, O.; Cavarzerani, A.; Bruni, A.; Farnia, A.; Sarpellon, M.; Ius, P.; Valfrè, C.; Stritoni, P.

1996-01-01

OBJECTIVE: To assess the diagnostic potential of transthoracic and transoesophageal echocardiography for the detection of traumatic cardiovascular injuries in patients suffering from severe blunt chest trauma. DESIGN: Prospective study over a three year period. SETTING: A regional cardiothoracic centre. PATIENTS: 134 consecutive patients (94 M/40 F; mean age 38 (SD 14) years) suffering from severe blunt chest trauma (injury severity score 33.5 (18.2)). Most patients (89%) were victims of motor vehicle accidents. EVALUATION: All patients underwent transthoracic and transoesophageal echocardiography within 8 h of admission. Aortography was performed in the first 20 patients and in a further five equivocal cases. RESULTS: Transthoracic echocardiography provided suboptimal images in 83 patients, detecting three aortic ruptures, 28 pericardial effusions (one cardiac tamponade), 35 left pleural effusions, and 15 myocardial contusions. Transoesophageal echocardiography was feasible in 131 patients and detected 14 aortic ruptures (13 at the isthmus), 40 pericardial effusions, 51 left pleural effusions, 34 periaortic haematomas, 45 myocardial contusions, right atrial laceration in one patient with cardiac tamponade, one tricuspid valve rupture, and one severe mitral regurgitation caused by annular disruption. For the detection of aortic rupture transoesophageal echocardiography showed 93% sensitivity, 98% specificity, and 98% accuracy. Time to surgery was significantly shorter (30 (12) v 71 (21) min; P < 0.05) for patients operated on only on the basis of transoesophageal echocardiographic findings. CONCLUSIONS: Transthoracic echocardiography has low diagnostic yield in severe blunt chest trauma, while transoesophageal echocardiography provides accurate diagnosis in a short time at the bedside, is inexpensive, minimally invasive, and does not interfere with other diagnostic or therapeutic procedures. Images PMID:8800997

Tension gastrothorax in a child presenting with abdominal pain.

PubMed

Hooker, Ross; Claudius, Ilene; Truong, Anh

2012-02-01

A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She had suffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs were appropriate for age. Physical examination was remarkable for decreased breath sounds to the left side of the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of the chest with mediastinal shift.

Rib Fracture Diagnosis in the Panscan Era.

PubMed

Murphy, Charles E; Raja, Ali S; Baumann, Brigitte M; Medak, Anthony J; Langdorf, Mark I; Nishijima, Daniel K; Hendey, Gregory W; Mower, William R; Rodriguez, Robert M

2017-12-01

With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury. We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes. Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4). Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

PubMed

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS ( P =0.001), respiratory rate ( P =0.001), and higher frequency of head ( P =0.02) and chest injuries ( P =0.04). The rate of VAP in PHI group was comparable to the TRI group ( P =0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma.

PubMed

Mosquera, Victor X; Marini, Milagros; Muñiz, Javier; Asorey-Veiga, Vanesa; Adrio-Nazar, Belen; Boix, Ricardo; Lopez-Perez, José M; Pradas-Montilla, Gonzalo; Cuenca, José J

2012-09-01

To develop a risk score based on physical examination and chest X-ray findings to rapidly identify major trauma patients at risk of acute traumatic aortic injury (ATAI). A multicenter retrospective study was conducted with 640 major trauma patients with associated blunt chest trauma classified into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data set included 76 consecutive ATAI and 304 NATAI patients from a single center, whereas the validation data set included 52 consecutive ATAI and 208 NATAI patients from three independent institutions. Bivariate analysis identified variables potentially influencing the presentation of aortic injury. Confirmed variables by logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1-4). Predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under receiver operating characteristic curve was 0.96. In the score data set, sensitivity was 93.42 %, specificity 85.85 %, Youden's index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31 % and specificity 85.1 %. Given the relative infrequency of traumatic aortic injury, which often leads to missed or delayed diagnosis, application of our score has the potential to draw necessary clinical attention to the possibility of aortic injury, thus providing the chance of a prompt specific diagnostic and therapeutic management.

Pancreaticoduodenectomy for paediatric pancreatic trauma with a decade of follow-up.

PubMed

Thatte, Madhav D; Vaze, Dhananjay

2014-01-01

Pancreaticoduodenal injuries are rare in children. They pose challenges for the treating surgeon in decision making with respect to diagnosis, surgical and post-surgical management. The management plan must be tailored to the nature and severity of trauma, patient profile, surgeon's expertise and the resources available at surgeon's disposal. We describe a pancreaticoduodenal injury in 3-year-old child with successful outcome and follow-up of a decade.

Outcome of penetrating chest injuries in an urban level I trauma center in the Netherlands.

PubMed

Heus, C; Mellema, J J; Giannakopoulos, G F; Zuidema, W P

2015-04-25

Most patients with penetrating chest injuries benefit from early treatment with chest tube drainage or surgery. Although penetrating chest injury is not uncommon, few descriptive studies are published, especially in Europe. The aim of this study was to review our experience and further improve our management of penetrating chest injuries in a level I trauma center in the Netherlands. All patients with penetrating chest injury between August 2004 and December 2012 were included. Demographics, mechanism of injury, physiological parameters, Injury Severity Scores (ISS), surgical and non-surgical treatment, length of intensive care unit (ICU) stay, length of hospital stay (LOS), complications and rate of mortality were collected. A total of 159 patients were analyzed. Patients included 116 (73 %) stab wounds and 34 (21 %) gunshot wounds. In 27 patients (17 %), cardiac injury was seen. The mean ISS was 12. Almost half of all patients (49 %) were treated with only chest tube drainage. Alternatively, surgical treatment was performed in 24 % of all cases. Anterolateral incision was most frequently used to gain access to the thoracic cavity. The mean LOS was 9 days. Among all patients, 17 % were admitted to the ICU with a mean stay of 3 days. In 18 (11 %) patients, one or more complications occurred. The 30-day mortality was 7.5 %. Patients presenting with penetrating chest injury are not uncommon in the Netherlands and can mostly be treated conservatively. In one-fourth of the patients, surgical treatment is performed. A structural and vigorous approach is needed for good clinical outcome.

Trauma-induced "Macklin effect" with pneumothorax and large pneumomediastinum, disguised by allergy.

PubMed

Di Saverio, Salomone; Kawamukai, Kenji; Biscardi, Andrea; Villani, Silvia; Zucchini, Luca; Tugnoli, Gregorio

2013-09-01

A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs (NSAIDS). The triage nurse assigned the patient to Accident & Emergency (A&E) doctor as probable allergic reaction to NSAIDS. Chest X-ray (CXR), ordered after 24 hours, revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax. Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum. The patient was conservatively treated since he was eupnoeic and hemodynamically stable. The pathophysiology of pneumomediastinum was first described by Macklin in 1939. The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum. In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.

Rupture of the right upper pulmonary vein and left atrium caused by blunt chest trauma.

PubMed

Osaka, Motoo; Nagai, Ryo; Koishizawa, Tadashi

2017-11-01

A 49-year-old man was transferred to our hospital by ambulance due to blunt chest trauma sustained in a car accident. Echocardiography and enhanced computed tomography showed hemopericardium without other vital organ damage. Emergent surgery was performed under strong suspicion of traumatic cardiac rupture. Careful inspection showed a rupture of the right upper pulmonary vein at the junction of the left atrium, a laceration of the inferior vena cava, and a left-side pericardium rupture, and they were repaired with running 4-0 polypropylene suture. Postoperative hemodynamics were stable. The patient was discharged ambulatory on postoperative day 15.

Treatment of haemothorax.

PubMed

Boersma, Wim G; Stigt, Jos A; Smit, Hans J M

2010-11-01

Haemothorax is a problem commonly encountered in medical practice and is most frequently related to open or closed chest trauma or to invasive procedures of the chest. Spontaneous haemothorax is less common and can have various causes, such as the use of anticoagulants, neoplasia, and rupture of pleural adhesions. Identification by radiography and thoracentesis is indicated and treatment of the underlying trauma should start immediately. After insertion of a large chest tube, antibiotic prophylaxis in trauma patients should be administered for 24 h. Further treatment depends on the haemodynamic stability of the patient, the volume of evacuated blood and the occurrence of persistent blood loss. Surgical exploration by VATS or thoracotomy is necessary if >1.500 ml of blood has accumulated and/or an ongoing production of >200 ml of blood per hour is observed. If the haemorrhage is less severe, careful investigation into the underlying cause must be performed and blood should be evacuated by tube thoracostomy. If clotted blood retained in spite of tube thoracostomy, intrapleural fibrinolytic therapy can be applied to breakdown clots and adhesions. If conservative treatment is insufficient, a surgical approach with VATS or thoracotomy is indicated to prevent subsequent complications. Copyright © 2010 Elsevier Ltd. All rights reserved.

Blunt Chest Trauma in Mice after Cigarette Smoke-Exposure: Effects of Mechanical Ventilation with 100% O2.

PubMed

Wagner, Katja; Gröger, Michael; McCook, Oscar; Scheuerle, Angelika; Asfar, Pierre; Stahl, Bettina; Huber-Lang, Markus; Ignatius, Anita; Jung, Birgit; Duechs, Matthias; Möller, Peter; Georgieff, Michael; Calzia, Enrico; Radermacher, Peter; Wagner, Florian

2015-01-01

Cigarette smoking (CS) aggravates post-traumatic acute lung injury and increases ventilator-induced lung injury due to more severe tissue inflammation and apoptosis. Hyper-inflammation after chest trauma is due to the physical damage, the drop in alveolar PO2, and the consecutive hypoxemia and tissue hypoxia. Therefore, we tested the hypotheses that 1) CS exposure prior to blunt chest trauma causes more severe post-traumatic inflammation and thereby aggravates lung injury, and that 2) hyperoxia may attenuate this effect. Immediately after blast wave-induced blunt chest trauma, mice (n=32) with or without 3-4 weeks of CS exposure underwent 4 hours of pressure-controlled, thoraco-pulmonary compliance-titrated, lung-protective mechanical ventilation with air or 100% O2. Hemodynamics, lung mechanics, gas exchange, and acid-base status were measured together with blood and tissue cytokine and chemokine concentrations, heme oxygenase-1 (HO-1), activated caspase-3, and hypoxia-inducible factor 1-α (HIF-1α) expression, nuclear factor-κB (NF-κB) activation, nitrotyrosine formation, purinergic receptor 2X4 (P2XR4) and 2X7 (P2XR7) expression, and histological scoring. CS exposure prior to chest trauma lead to higher pulmonary compliance and lower PaO2 and Horovitz-index, associated with increased tissue IL-18 and blood MCP-1 concentrations, a 2-4-fold higher inflammatory cell infiltration, and more pronounced alveolar membrane thickening. This effect coincided with increased activated caspase-3, nitrotyrosine, P2XR4, and P2XR7 expression, NF-κB activation, and reduced HIF-1α expression. Hyperoxia did not further affect lung mechanics, gas exchange, pulmonary and systemic cytokine and chemokine concentrations, or histological scoring, except for some patchy alveolar edema in CS exposed mice. However, hyperoxia attenuated tissue HIF-1α, nitrotyrosine, P2XR7, and P2XR4 expression, while it increased HO-1 formation in CS exposed mice. Overall, CS exposure aggravated post-traumatic inflammation, nitrosative stress and thereby organ dysfunction and injury; short-term, lung-protective, hyperoxic mechanical ventilation have no major beneficial effect despite attenuation of nitrosative stress, possibly due to compensation of by regional alveolar hypoxia and/or consecutive hypoxemia, resulting in down-regulation of HIF-1α expression.

Pelvic-fracture urethral injury in children

PubMed Central

Hagedorn, Judith C.; Voelzke, Bryan B.

2015-01-01

Objective To review paediatric posterior urethral injuries and the current potential management options; because urethral injury due to pelvic fracture in children is rare and has a low incidence, the management of this type of trauma and its complications remains controversial. Methods We reviewed previous reports identified by searching the PubMed Medline electronic database for clinically relevant articles published in the past 25 years. The search was limited to the keywords ‘pediatric’, ‘pelvic fracture’, ‘urethral injury’, ‘stricture’, ‘trauma’ and ‘reconstruction’. Results Most paediatric urethral injuries are a result of pelvic fractures after high-impact blunt trauma. After the diagnosis, immediate bladder drainage via a suprapubic cystotomy, or urethral realignment, are the initial management options, except for a possible immediate primary repair in girls. The common complications of pelvic fracture-associated urethral injury include urethral stricture formation, incontinence and erectile dysfunction. Excellent results can be achieved with delayed urethroplasty for pelvic fracture-associated urethral injuries. Conclusion Traumatic injury to the paediatric urethra is rare and calls for an immediate diagnosis and management. These devastating injuries have a high complication rate and therefore a close follow-up is warranted to assure adequate delayed repair by a reconstructive urologist. PMID:26019977

Penetrating trauma; experience from Southwest Finland between 1997 and 2011, a retrospective descriptive study.

PubMed

Inkinen, J; Kirjasuo, K; Gunn, J; Kuttila, K

2015-08-01

(1) There is lack of epidemiological data on penetrating trauma in European countries. (2) In Finland most acts of violence are performed under the influence of alcohol. The aim of this study was to determine the incidence and types of injury, treatment and survival of patients with penetrating injuries to the thorax and abdomen. This study includes two trauma centers with combined catchment area of approximately 720,000 patients. Patients were identified from patient records using ICD-10 codes. Patients were predominantly young males and they were stab victims. The average yearly incidence for penetrating trauma was 0.9/100,000 inhabitants. Thirteen percent of patients admitted gave a negative toxicology screen or breathalyzer test for alcohol. Twenty two percent of wounds were self-inflicted. Fifty five percent of patients received a chest tube and 30 patients (23%) underwent emergent thoracotomy after sustaining critical injury to the thorax. A considerable proportion (12%) of the study group also later died due to alcohol and/or violence, highlighting the psychosocial co-morbidity among penetrating trauma victims. Chest tube insertion is a skill to be mastered by any on-call physician. This simple procedure can be potentially life-saving. There is also a call for assessment of psychosocial well-being among penetrating trauma victims.

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma

PubMed Central

Chou, Yi-Pin; Kuo, Liang-Chi; Soo, Kwan-Ming; Tarng, Yih-Wen; Chiang, Hsin-I.; Huang, Fong-Dee; Lin, Hsing-Lin

2014-01-01

OBJECTIVES Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS. METHODS Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries. RESULTS During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay. CONCLUSIONS When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries. PMID:24242850

Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation.

PubMed

Yang, Euiseok; Jeong, WonJoon; Lee, JunWan; Kim, SeungWhan

2014-11-01

Hemothorax is not an uncommon cardiopulmonary resuscitation(CPR)–related complication. But hemothorax related to azygos vein injury (AVI) is a rare condition following blunt chest trauma, with no report of CPR-related AVI in the literature. We present a case of azygosve in rupture in a middle-aged woman after repeated chest compression during 1 hour of CPR. She eventually presented with massive hemothorax due to azygos vein rupture diagnosed by computed tomography (CT). When faced with a patient with massive hemothorax after chest compression, azygos vein rupture should be considered as a complication.

Early evaluation of cardiac injury by two-dimensional echocardiography in patients suffering blunt chest trauma.

PubMed

Beggs, C W; Helling, T S; Evans, L L; Hays, L V; Kennedy, F R; Crouse, L J

1987-05-01

The availability of two-dimensional echocardiography as a clinical tool has led to an interest in its applicability, usefulness, and reliability in the evaluation of blunt cardiac trauma. Forty patients who sustained objective evidence of blunt chest trauma were evaluated at our institution using serial ECGs, creatine phosphokinase (CPK) isoenzyme determinations, and two-dimensional echocardiography. Twenty patients (50%) manifested evidence of cardiac injury as demonstrated by abnormal ECGs, elevated CPK isoenzymes, or abnormal echocardiograms. Nine (23%) patients had abnormal echocardiograms with findings of pericardial effusions in four, chamber enlargement in three, and echodense areas of the right ventricle in two. There was no correlation with ECG changes or the presence of CPK isoenzymes. Based on these observations we believe echocardiography can be used as a noninvasive modality to complement other clinical tools in the detection of blunt cardiac injury.

Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania

PubMed Central

2011-01-01

Background Chest injuries constitute a continuing challenge to the trauma or general surgeon practicing in developing countries. This study was conducted to outline the etiological spectrum, injury patterns and short term outcome of these injuries in our setting. Patients and methods This was a prospective study involving chest injury patients admitted to Bugando Medical Centre over a six-month period from November 2009 to April 2010 inclusive. Results A total of 150 chest injury patients were studied. Males outnumbered females by a ratio of 3.8:1. Their ages ranged from 1 to 80 years (mean = 32.17 years). The majority of patients (72.7%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 50.7% of patients. Chest wall wounds, hemothorax and rib fractures were the most common type of injuries accounting for 30.0%, 21.3% and 20.7% respectively. Associated injuries were noted in 56.0% of patients and head/neck (33.3%) and musculoskeletal regions (26.7%) were commonly affected. The majority of patients (55.3%) were treated successfully with non-operative approach. Underwater seal drainage was performed in 39 patients (19.3%). One patient (0.7%) underwent thoracotomy due to hemopericardium. Thirty nine patients (26.0%) had complications of which wound sepsis (14.7%) and complications of long bone fractures (12.0%) were the most common complications. The mean LOS was 13.17 days and mortality rate was 3.3%. Using multivariate logistic regression analysis, associated injuries, the type of injury, trauma scores (ISS, RTS and PTS) were found to be significant predictors of the LOS (P < 0.001), whereas mortality was significantly associated with pre-morbid illness, associated injuries, trauma scores (ISS, RTS and PTS), the need for ICU admission and the presence of complications (P < 0.001). Conclusion Chest injuries resulting from RTCs remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce the incidence of chest injuries in this region. PMID:21244706

Missed injuries in the era of the trauma scan.

PubMed

Lawson, Christy M; Daley, Brian J; Ormsby, Christine B; Enderson, Blaine

2011-02-01

A rapid computed tomography technique or "trauma scan" (TS) provides high-resolution studies of the head, cervical spine, chest, abdomen, and pelvis. We sought to determine whether TS has decreased missed injuries. A previous study of TS found a 3% missed rate. After institutional review board approval, trauma patients from January 2001 through December 2008 were reviewed for delayed diagnosis (DD) of injury to the head, cervical spine, chest, abdomen, or pelvis. Missed extremity injuries were excluded. Injury Severity Score, length of stay, type of injury, outcomes, and days to detection were captured. Of 26,264 patients reviewed, 90 patients had DD, with an incidence of 0.34%. DD most commonly presented on day 2. Injuries included 16 bowel/mesentery, 12 spine, 11 pelvic, 8 spleen, 6 diaphragm, 5 clavicle, 4 scapula, 4 cervical spine, 4 intracranial, 4 sternum, 3 maxillofacial, 3 liver, 2 heart/aorta, 2 vascular, 2 urethra/bladder, 2 pneumothorax, and 2 pancreas/common bile duct. DD resulted in 1 death, 6 prolonged intensive care unit stays, 19 operative interventions, and 38 additional interventions. TS is an effective way of evaluating trauma patients for intracranial, cervical spine, chest, abdomen, and pelvic injuries that have the potential to impact morbidity and mortality. The incidence of injuries missed in these crucial areas has been reduced at our institution by the use of this radiographic modality. The most common missed injury remains bowel, and so a high index of suspicion and the tertiary survey must remain a mainstay of therapy.

Nonoperative Management of a Large Extrapleural Hematoma after Blunt Chest Trauma.

PubMed

Gorospe, Luis; Fernández-Méndez, María Ángeles; Ayala-Carbonero, Ana; Cabañero-Sánchez, Alberto; Muñoz-Molina, Gemma María

2016-08-01

An extrapleural hematoma (EH) is an uncommon and potentially life-threatening condition defined as the accumulation of blood in the extrapleural space between the parietal pleura and the endothoracic fascia. EH usually occurs after blunt thoracic trauma causing fractures of the sternum and ribs, which can tear the intercostal or internal mammary vessels. Typical radiological findings of EH are a biconvex opacity on the involved hemithorax and the so-called displaced "extrapleural fat sign." We present a case of a 36-year-old man with an isolated scapular fracture after a high-energy blunt chest trauma complicated with a large contralateral EH that was successfully managed nonoperatively with transcatheter arterial embolization (TAE) and image-guided drainage with a pig-tail catheter. To the best of our knowledge there is only one previous report describing a large EH after blunt thoracic trauma without rib fractures. Only two previous cases of large EHs have been treated initially with TAE, but both patients ultimately required open surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with EH can present with respiratory distress and hypotension, so early identification is important to facilitate proper treatment. EH has characteristic radiological findings, and contrast-enhanced computed tomography is not only the best imaging tool for confirming an EH, but also the best technique for detecting the source of the bleeding and other serious thoracic complications that may not be evident on chest x-ray studies. Copyright © 2016 Elsevier Inc. All rights reserved.

First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography.

PubMed

Ianniello, Stefania; Di Giacomo, Vincenza; Sessa, Barbara; Miele, Vittorio

2014-09-01

Combined clinical examination and supine chest radiography have shown low accuracy in the assessment of pneumothorax in unstable patients with major chest trauma during the primary survey in the emergency room. The aim of our study was to evaluate the diagnostic accuracy of extended-focused assessment with sonography in trauma (e-FAST), in the diagnosis of pneumothorax, compared with the results of multidetector computed tomography (MDCT) and of invasive interventions (thoracostomy tube placement). This was a retrospective case series involving 368 consecutive unstable adult patients (273 men and 95 women; average age, 25 years; range, 16-68 years) admitted to our hospital's emergency department between January 2011 and December 2012 for major trauma (Injury Severity Score ≥ 15). We evaluated the accuracy of thoracic ultrasound in the detection of pneumothorax compared with the results of MDCT and invasive interventions (thoracostomy tube placement). Institutional review board approval was obtained prior to commencement of this study. Among the 736 lung fields included in the study, 87 pneumothoraces were detected with thoracic CT scans (23.6%). e-FAST detected 67/87 and missed 20 pneumothoraces (17 mild, 3 moderate). The diagnostic performance of ultrasound was: sensitivity 77% (74% in 2011 and 80% in 2012), specificity 99.8%, positive predictive value 98.5%, negative predictive value 97%, accuracy 97.2% (67 true positive; 668 true negative; 1 false positive; 20 false negative); 17 missed mild pneumothoraces were not immediately life-threatening (thickness less than 5 mm). Thoracic ultrasound (e-FAST) is a rapid and accurate first-line, bedside diagnostic modality for the diagnosis of pneumothorax in unstable patients with major chest trauma during the primary survey in the emergency room.

Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair.

PubMed

Mayberry, John C; Ham, L Bruce; Schipper, Paul H; Ellis, Thomas J; Mullins, Richard J

2009-03-01

Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown. Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair. Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (>6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion. A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

PubMed Central

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role. PMID:29796145

Multidetector CT of blunt traumatic venous injuries in the chest, abdomen, and pelvis.

PubMed

Holly, Brian P; Steenburg, Scott D

2011-01-01

Venous injuries as a result of blunt trauma are rare. Even though current protocols for multidetector computed tomography (CT) of patients with trauma are designed to evaluate primarily the solid organs and arteries, blunt venous injuries may nevertheless be identified, or at least suspected, on the basis of the multidetector CT findings. Venous injuries are associated with high morbidity and mortality rates. Diagnosis of a possible venous injury is crucial because the physical findings of a venous injury are nonspecific and may be absent. This article aims to make the radiologist aware of various venous injuries caused by blunt trauma and to provide helpful hints to aid in the identification of venous injuries. Multidetector CT technology, in combination with interactive manipulation of the raw dataset, can be useful in the creation of multiplanar reconstructed images and in the identification of a venous injury caused by blunt trauma. Familiarity with direct and indirect signs of venous injuries, as well as with examples of blunt traumatic venous injuries in the chest, abdomen, and pelvis, will help in the diagnosis of these injuries.

Randomised crossover trial of rate feedback and force during chest compressions for paediatric cardiopulmonary resuscitation.

PubMed

Gregson, Rachael Kathleen; Cole, Tim James; Skellett, Sophie; Bagkeris, Emmanouil; Welsby, Denise; Peters, Mark John

2017-05-01

To determine the effect of visual feedback on rate of chest compressions, secondarily relating the forces used. Randomised crossover trial. Tertiary teaching hospital. Fifty trained hospital staff. A thin sensor-mat placed over the manikin's chest measured rate and force. Rescuers applied compressions to the same paediatric manikin for two sessions. During one session they received visual feedback comparing their real-time rate with published guidelines. Primary: compression rate. Secondary: compression and residual forces. Rate of chest compressions (compressions per minute (compressions per minute; cpm)) varied widely (mean (SD) 111 (13), range 89-168), with a fourfold difference in variation during session 1 between those receiving and not receiving feedback (108 (5) vs 120 (20)). The interaction of session by feedback order was highly significant, indicating that this difference in mean rate between sessions was 14 cpm less (95% CI -22 to -5, p=0.002) in those given feedback first compared with those given it second. Compression force (N) varied widely (mean (SD) 306 (94); range 142-769). Those receiving feedback second (as opposed to first) used significantly lower force (adjusted mean difference -80 (95% CI -128 to -32), p=0.002). Mean residual force (18 N, SD 12, range 0-49) was unaffected by the intervention. While visual feedback restricted excessive compression rates to within the prescribed range, applied force remained widely variable. The forces required may differ with growth, but such variation treating one manikin is alarming. Feedback technologies additionally measuring force (effort) could help to standardise and define effective treatments throughout childhood. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation?

PubMed

Wilson, Heather; Ellsmere, James; Tallon, John; Kirkpatrick, Andrew

2009-09-01

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes. A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status-dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures. In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p=0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p=0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces. The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.

Real-time feedback can improve infant manikin cardiopulmonary resuscitation by up to 79%--a randomised controlled trial.

PubMed

Martin, Philip; Theobald, Peter; Kemp, Alison; Maguire, Sabine; Maconochie, Ian; Jones, Michael

2013-08-01

European and Advanced Paediatric Life Support training courses. Sixty-nine certified CPR providers. CPR providers were randomly allocated to a 'no-feedback' or 'feedback' group, performing two-thumb and two-finger chest compressions on a "physiological", instrumented resuscitation manikin. Baseline data was recorded without feedback, before chest compressions were repeated with one group receiving feedback. Indices were calculated that defined chest compression quality, based upon comparison of the chest wall displacement to the targets of four, internationally recommended parameters: chest compression depth, release force, chest compression rate and compression duty cycle. Baseline data were consistent with other studies, with <1% of chest compressions performed by providers simultaneously achieving the target of the four internationally recommended parameters. During the 'experimental' phase, 34 CPR providers benefitted from the provision of 'real-time' feedback which, on analysis, coincided with a statistical improvement in compression rate, depth and duty cycle quality across both compression techniques (all measures: p<0.001). Feedback enabled providers to simultaneously achieve the four targets in 75% (two-finger) and 80% (two-thumb) of chest compressions. Real-time feedback produced a dramatic increase in the quality of chest compression (i.e. from <1% to 75-80%). If these results transfer to a clinical scenario this technology could, for the first time, support providers in consistently performing accurate chest compressions during infant CPR and thus potentially improving clinical outcomes. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Development of a simple algorithm to guide the effective management of traumatic cardiac arrest.

PubMed

Lockey, David J; Lyon, Richard M; Davies, Gareth E

2013-06-01

Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest. We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician - paramedic pre-hospital trauma service. The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax. The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis.

PubMed

Hammer, Mark M; Raptis, Demetrios A; Mellnick, Vincent M; Bhalla, Sanjeev; Raptis, Constantine A

2017-04-01

Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.

Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital.

PubMed

Alam Khan, T; Jamil Khattak, Y; Awais, M; Alam Khan, A; Husen, Y; Nadeem, N; Rehman, A

2015-06-01

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children. A total of 176 consecutive children below the age of 15 years and having Glasgow Coma Scale score greater than 12, who presented to the emergency department of a tertiary care hospital with a history of recent trauma, were retrospectively reviewed. All the children had undergone a thorough clinical examination followed by complete trauma series radiographs, according to the American College of Surgery guidelines. A total of 558 radiographs were reviewed by a consultant pediatric radiologist including 528 trauma series radiographs and 30 additional radiographs. Among the trauma series radiographs, 35 (6.63 %) had evidence of injury; 24 (4.54 %) and 11 (2.08 %) involving the chest and pelvic regions, respectively. All children with normal physical examination had normal cervical spine and chest radiographs. Among the 11 positive pelvic X-rays, only two had radiological signs of injury in the absence of localizing physical signs, and all these children were less than 3 years of age. In all the remaining cases, children had localizing signs on physical examination. Out of the 30 additional X-rays, 27 (90 %) had radiological evidence of injury. The routine use of entire radiological trauma series in alert pediatric patients with a normal physical examination has a very low yield. In these children, the localizing signs and symptoms can help us in determining the specific radiological examination to be utilized.

Evaluation of chest tube administration of tissue plasminogen activator to treat retained hemothorax.

PubMed

Stiles, P J; Drake, Rachel M; Helmer, Stephen D; Bjordahl, Paul M; Haan, James M

2014-06-01

When retained hemothorax occurs, video-assisted thoracoscopy or thoracotomy is performed, but recently, tissue plasminogen activator (tPA) has been used. This study evaluated intrapleural tPA use for retained traumatic hemothoraces. A retrospective review was conducted of trauma patients treated with intrapleural tPA for retained hemothorax. Data included demographics, past medical and surgical histories, injury details, treatment details, and outcomes. Seven patients (median age = 47 years, male = 6, blunt trauma = 6) met study criteria. All patients received a chest tube. Six patients later received computed tomography-guided drains for tPA infusion. Number of tPA treatments per patient varied from 1 to 5. Median total tPA dosage was 24 mg. Median time from injury to chest tube placement was 11 days and from chest tube placement to first tPA treatment was 4 days. No patients required a video-assisted thoracoscopy; however, 1 patient required thoracotomy. There were no deaths or bleeding complications attributed to intrapleural tPA. Although future studies are needed to identify optimum treatment guidelines, intrapleural tPA appears to be a safe and efficacious treatment option. Copyright © 2014 Elsevier Inc. All rights reserved.

Accuracy of the Interpretation of Chest Radiographs for the Diagnosis of Paediatric Pneumonia

PubMed Central

Elemraid, Mohamed A.; Muller, Michelle; Spencer, David A.; Rushton, Stephen P.; Gorton, Russell; Thomas, Matthew F.; Eastham, Katherine M.; Hampton, Fiona; Gennery, Andrew R.; Clark, Julia E.

2014-01-01

Introduction World Health Organization (WHO) radiological classification remains an important entry criterion in epidemiological studies of pneumonia in children. We report inter-observer variability in the interpretation of 169 chest radiographs in children suspected of having pneumonia. Methods An 18-month prospective aetiological study of pneumonia was undertaken in Northern England. Chest radiographs were performed on eligible children aged ≤16 years with clinical features of pneumonia. The initial radiology report was compared with a subsequent assessment by a consultant cardiothoracic radiologist. Chest radiographic changes were categorised according to the WHO classification. Results There was significant disagreement (22%) between the first and second reports (kappa = 0.70, P<0.001), notably in those aged <5 years (26%, kappa = 0.66, P<0.001). The most frequent sources of disagreement were the reporting of patchy and perihilar changes. Conclusion This substantial inter-observer variability highlights the need for experts from different countries to create a consensus to review the radiological definition of pneumonia in children. PMID:25148361

Reliable Real-time Calculation of Heart-rate Complexity in Critically Ill Patients Using Multiple Noisy Waveform Sources

DTIC Science & Technology

2014-01-01

systems Machine learning Automatic data processing 1 Introduction Heart-rate complexity (HRC) is a method of quantifying the amount of complex...5. Batchinsky AI, Skinner J, Necsoiu C, et al. New measures of heart-rate complexity: effect of chest trauma and hemorrhage. J Trauma. 2010;68:1178–85

Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography.

PubMed

Hoffstetter, Patrick; Dornia, Christian; Schäfer, Stephan; Wagner, Merle; Dendl, Lena M; Stroszczynski, Christian; Schreyer, Andreas G

2014-01-01

Rib series (RS) are a special radiological technique to improve the visualization of the bony parts of the chest. The aim of this study was to evaluate the diagnostic accuracy of rib series in minor thorax trauma. Retrospective study of 56 patients who received RS, 39 patients where additionally evaluated by plain chest film (PCF). All patients underwent a computed tomography (CT) of the chest. RS and PCF were re-read independently by three radiologists, the results were compared with the CT as goldstandard. Sensitivity, specificity, negative and positive predictive value were calculated. Significance in the differences of findings was determined by McNemar test, interobserver variability by Cohens kappa test. 56 patients were evaluated (34 men, 22 women, mean age =61 y.). In 22 patients one or more rib fracture could be identified by CT. In 18 of these cases (82%) the correct diagnosis was made by RS, in 16 cases (73%) the correct number of involved ribs was detected. These differences were significant (p = 0.03). Specificity was 100%, negative and positive predictive value were 85% and 100%. Kappa values for the interobserver agreement was 0.92-0.96. Sensitivity of PCF was 46% and was significantly lower (p = 0.008) compared to CT. Rib series does not seem to be an useful examination in evaluating minor thorax trauma. CT seems to be the method of choice to detect rib fractures, but the clinical value of the radiological proof has to be discussed and investigated in larger follow up studies.

Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

PubMed

Garg, Ravi Kumar; Mahajan, Jai Kumar

2017-12-01

Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries. A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed. Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies. Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.

Guide to thoracic imaging.

PubMed

Skinner, Sarah

2015-08-01

Thoracic imaging is commonly ordered in general practice. Guidelines exist for ordering thoracic imaging but few are specific for general practice. This article summarises current indications for imaging the thorax with chest X-ray and computed tomography. A simple frame-work for interpretation of the chest X-ray, suitable for trainees and practitioners providing primary care imaging in rural and remote locations, is presented. Interpretation of thoracic imaging is best done using a systematic approach. Radiological investigation is not warranted in un-complicated upper respiratory tract infections or asthma, minor trauma or acute-on-chronic chest pain.

Sickle cell disease in children.

PubMed

Meier, Emily Riehm; Miller, Jeffery L

2012-05-07

Early identification of infants with sickle cell disease (SCD) by newborn screening, now universal in all 50 states in the US, has improved survival, mainly by preventing overwhelming sepsis with the early use of prophylactic penicillin. Routine transcranial Doppler screening with the institution of chronic transfusion decreases the risk of stroke from 10% to 1% in paediatric SCD patients. Hydroxyurea decreases the number and frequency of painful crises, acute chest syndromes and number of blood transfusions in children with SCD. Genetic research continues to be driven toward the prevention and ultimate cure of SCD before adulthood. This review focuses on clinical manifestations and therapeutic strategies for paediatric SCD as well as the evolving topic of gene-focused prevention and therapy.

Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank.

PubMed

Dehghan, Niloofar; de Mestral, Charles; McKee, Michael D; Schemitsch, Emil H; Nathens, Avery

2014-02-01

Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in polytrauma patients. The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical outcomes associated with flail chest injuries. Patients with a flail chest injury admitted from 2007 to 2009 were included in the analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. Flail chest injury was identified in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Significant head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and surgical fixation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days. ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy. Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category compared with those without a head injury. Patients who have sustained a flail chest have significant morbidity and mortality. More than 99% of these patients were treated nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high rates of morbidity and mortality in patients with a flail chest injury, alternate methods of treatment including more consistent use of epidural catheters for pain or surgical fixation need to be investigated with large randomized controlled trials. Epidemiologic/prognostic study, level IV.

Using a safety net and following the safety instructions could prevent half the paediatric trampoline injuries.

PubMed

Rättyä, J; Serlo, W

2008-08-01

The number of recreational trampolines in Finnish households has increased. There also appears to be a drastic increase in trampoline-related injuries among paediatric patients. The aim of this study was to quantify and describe trampoline-related injuries in North Finnish paediatric patients. A retrospective analysis of medical data was used in the study, covering children 16 years and younger treated for trampoline-related injuries at Oulu University Hospital over a five-month period of time from May 1 to September 30, 2005. Medical records were reviewed and additional details regarding the injuries were obtained by questionnaire. Altogether 76 patients were treated for trampoline-related injuries, which represented 13.4 % of all paediatric accidental trauma patients. In 57 accidents (86 %), there had been multiple jumpers on the trampoline. Twenty-five of the injuries (38 %) had occurred on the trampoline, in 25 cases (38 %) a child had fallen off, in 8 cases (12 %) there had been a collision with another jumper and the person had jumped onto a trampoline from a high platform in 5 incidents (8 %). Only 3 children (5 %) hurt themselves on the trampoline when jumping alone. Orthopaedic procedures requiring general anaesthesia were necessary in a total of 31 cases (41 %). The study shows that 50 % of traumas (falling off and collisions) could have been avoided by using a safety net and by jumping one at a time. The importance of following safety instructions and the need for a safety net should be emphasised to both the supervising adults and the children.

The significance of routine thoracic computed tomography in patients with blunt chest trauma.

PubMed

Çorbacıoğlu, Seref Kerem; Er, Erhan; Aslan, Sahin; Seviner, Meltem; Aksel, Gökhan; Doğan, Nurettin Özgür; Güler, Sertaç; Bitir, Aysen

2015-05-01

The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma. This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients. Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. Copyright © 2014 Elsevier Ltd. All rights reserved.

Vented chest seals for prevention of tension pneumothorax in a communicating pneumothorax.

PubMed

Kotora, Joseph G; Henao, Jose; Littlejohn, Lanny F; Kircher, Sara

2013-11-01

Tension pneumothorax accounts for 3%-4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise. A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application. A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin(®), n = 8; Sentinel(®), n = 8, SAM(®), n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period. The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place. HyFin(®), SAM(®), and Sentinel(®) vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma. Published by Elsevier Inc.

Tube thoracostomy: the struggle to the "standard of care".

PubMed

Monaghan, Sean F; Swan, Kenneth G

2008-12-01

Tube thoracostomy for thoracic injuries has been standard for only the last 40 years. Its theoretic roots trace back to World War II, where the goal of treatment was restoration of intrathoracic organ function. Thoracentesis was used to evacuate the hemopneumothorax resulting from chest trauma and that compromised pulmonary function. Experience gained in military and civilian hospitals contributed to the development of tube thoracostomy as an alternative treatment for patients with chest trauma. Progress stalled due to technologic problems and unacceptable complications associated with tube thoracostomy use during the Korean War. Technology improved, however, as did the success of thoracostomy, and it eventually become the standard of care, first in the civilian community and, ultimately, in the Vietnam War.

Role of focused assessment with sonography for trauma as a screening tool for blunt abdominal trauma in young children after high energy trauma.

PubMed

Tummers, W; van Schuppen, J; Langeveld, H; Wilde, J; Banderker, E; van As, A

2016-06-01

The objective of the study was to review the utility of focused assessement with sonography for trauma (FAST) as a screening tool for blunt abdominal trauma (BAT) in children involved in high energy trauma (HET), and to determine whether a FAST could replace computed tomography (CT) in clinical decision-making regarding paediatric BAT. Children presented at the Trauma Unit of the Red Cross War Memorial Children's Hospital, Cape Town, after HET, and underwent both a physical examination and a FAST. The presence of free fluid in the abdomen and pelvis was assessed using a FAST. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for identifying intraabdominal injury were calculated for the physical examination and the FAST, both individually and when combined. Seventy-five patients were included as per the criteria for HET as follows: pedestrian motor vehicle crashes (MVCs) ( n = 46), assault ( n = 14), fall from a height ( n = 9), MVC passenger ( n = 4) and other ( n = 2). The ages of the patients ranged from 3 months to 13 years. The sensitivity of the physical examination was 0.80, specificity 0.83, PPV 0.42 and NPV 0.96. The sensitivity of the FAST was 0.50, specificity 1.00, PPV 1.00 and NPV 0.93. Sensitivity increased to 0.90 when the physical examination was combined with the FAST. Nonoperative management was used in 73 patients. Two underwent an operation. A FAST should be performed in combination with a physical examination on every paediatric patient involved in HET to detect BAT. When both are negative, nonoperative management can be implemented without fear of missing a clinically significant injury. FAST is a safe, effective and easily accessible alternative to CT, which avoids ionising radiation and aids in clinical decision-making.

Diagnostic Accuracy of Ultrasonography and Radiography in Initial Evaluation of Chest Trauma Patients.

PubMed

Vafaei, Ali; Hatamabadi, Hamid Reza; Heidary, Kamran; Alimohammadi, Hosein; Tarbiyat, Mohammad

2016-01-01

Application of chest radiography for all multiple trauma patients is associated with a significant increase in total costs, exposure to radiation, and overcrowding of the emergency department. Ultrasound has been introduced as an alternative diagnostic tool in this regard. The aim of the present study is to compare the diagnostic accuracy of chest ultrasonography and radiography in detection of traumatic intrathoracic injuries. In the present prospective cross-sectional study, patients with traumatic intrathoracic injuries, who were referred to the emergency department from December 2013 to December 2014, were assessed. The patients underwent bedside ultrasound, radiographic and computed tomography (CT) scan examinations based on ATLS recommendations. Screening performance characteristics of ultrasonography and radiography were compared using SPSS 21.0. Chest CT scan was considered as gold standard. 152 chest trauma patients with a mean age of 31.4 ± 13.8 years (range: 4 ‒ 67), were enrolled (77.6% male). Chest CT scan showed pulmonary contusion in 48 (31.6%) patients, hemothorax in 29 (19.1%), and pneumothorax in 55 (36.2%) cases. Area under the ROC curve of ultrasonography in detection of pneumothorax, hemothorax, and pulmonary contusion were 0.91 (95% CI: 0.86‒0.96), 0.86 (95% CI: 0.78‒0.94), and 0.80 (95% CI: 0.736‒0.88), respectively. Area under the ROC curve of radiography was 0.80 (95% CI: 0.736‒0.87) for detection of pneumothorax, 0.77 (95% CI: 0.68‒0.86) for hemothorax, and 0.58 (95% CI: 0.5‒0.67) for pulmonary contusion. Comparison of areas under the ROC curve declared the significant superiority of ultrasonography in detection of pneumothorax (p = 0.02) and pulmonary contusion (p < 0.001). However, the diagnostic value of the two tests was equal in detection of hemothorax (p = 0.08). The results of the present study showed that ultrasonography is preferable to radiography in the initial evaluation of patients with traumatic injuries to the thoracic cavity.

Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis

PubMed Central

Gordic, S; Hodel, S; Simmen, H-P; Brueesch, M; Frauenfelder, T; Wanner, G; Sprengel, K

2015-01-01

Objective: To determine the number of imaging examinations, radiation dose and the time to complete trauma-related imaging in multiple trauma patients before and after introduction of whole-body CT (WBCT) into early trauma care. Methods: 120 consecutive patients before and 120 patients after introduction of WBCT into the trauma algorithm of the University Hospital Zurich were compared regarding the number and type of CT, radiography, focused assessment with sonography for trauma (FAST), additional CT examinations (defined as CT of the same body regions after radiography and/or FAST) and the time to complete trauma-related imaging. Results: In the WBCT cohort, significantly more patients underwent CT of the head, neck, chest and abdomen (p < 0.001) than in the non-WBCT cohort, whereas the number of radiographic examinations of the cervical spine, chest and pelvis and of FAST examinations were significantly lower (p < 0.001). There were no significant differences between cohorts regarding the number of radiographic examinations of the upper (p = 0.56) and lower extremities (p = 0.30). We found significantly higher effective doses in the WBCT (29.5 mSv) than in the non-WBCT cohort (15.9 mSv; p < 0.001), but fewer additional CT examinations for completing the work-up were needed in the WBCT cohort (p < 0.001). The time to complete trauma-related imaging was significantly shorter in the WBCT (12 min) than in the non-WBCT cohort (75 min; p < 0.001). Conclusion: Including WBCT in the initial work-up of trauma patients results in higher radiation doses, but fewer additional CT examinations are needed, and the time for completing trauma-related imaging is shorter. Advances in knowledge: WBCT in trauma patients is associated with a high radiation dose of 29.5 mSv. PMID:25594105

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma.

PubMed

Chou, Yi-Pin; Kuo, Liang-Chi; Soo, Kwan-Ming; Tarng, Yih-Wen; Chiang, Hsin-I; Huang, Fong-Dee; Lin, Hsing-Lin

2014-07-01

Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS. Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries. During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay. When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

Chest Trauma in Athletic Medicine.

PubMed

Phillips, Nicholas R; Kunz, Derek E

2018-03-01

While overall sports participation continues at high rates, chest injuries occur relatively infrequently. Many conditions of chest injury are benign, related to simple contusions and strains, but the more rare, severe injuries carry a much higher risk of morbidity and mortality than the typical issues encountered in athletic medicine. Missed or delayed diagnosis can prove to be catastrophic. Sports medicine providers must be prepared to encounter a wide range of traumatic conditions relating to the torso, varying from the benign chest wall contusion to the life-threatening tension pneumothorax. Basic field-side management should be rapid and focused, using the standardized approach of Advanced Traumatic Life Support protocol. Early and appropriate diagnosis and management can help allow safe and enjoyable sports participation.

Tomographic aspects of penetrating thoracic trauma: injuries from firearms and other weapons.

PubMed

de Melo, Alessandro Severo Alves; Moreira, Luiza Beatriz Melo; Pessoa, Fernanda Miraldi Clemente; Saint-Martin, Nara; Ancilotti Filho, Roger; Souza, Arthur Soares; Marchiori, Edson

2017-01-01

The aim of this study was to analyze the various computed tomography findings in penetrating chest trauma, as well as to determine the frequency and extent of the lesions. We studied the computed tomography findings from 40 cases of penetrating thoracic trauma, of which 35 (85.8%) were gunshot wounds and 5 (14.2%) were caused by another type of weapon. Pulmonary lesions were found in 39 cases (97.5%), manifesting as contusions in 34 cases (85%), atelectasis in 8 (20%), lacerations in 1 (2.5%) and hematomas in 1 (2.5%). Hemothorax was seen in 31 cases (77.5%), and pneumothorax was seen in 22 cases (55%). Mediastinal lesions were observed in 8 cases (20%), including mediastinal hematoma in 3 cases (7.5%), hemopericardium in 3 (7.5%), and pneumomediastinum in 2 (5%). Diaphragmatic rupture was seen in 2 cases (5%). In patients with penetrating thoracic trauma, computed tomography of the chest is an important tool for characterizing the affected organs and evaluating the path of injury, as well as the severity and extent of the lesions. The images obtained are also useful in estimating the risk of death and determining the best therapeutic approach.

Surgical management of traumatic tricuspid insufficiency.

PubMed

Zhang, Zhiqi; Yin, Kanhua; Dong, Lili; Sun, Yongxin; Guo, Changfa; Lin, Yi; Wang, Chunsheng

2017-06-01

This study reviews our experience with traumatic tricuspid insufficiency (TTI) following blunt chest trauma. From January 2010 to June 2016, 10 patients (nine males, mean age 49.0 ± 12.4 years) underwent surgical treatment of TTI following blunt chest trauma. The mean intervals between trauma and diagnosis and between trauma and surgery were 74.1 and 81.8 months, respectively. Preoperatively, all patients exhibited severe tricuspid regurgitation. Five patients underwent tricuspid valve repair, and the remaining patients underwent valve replacement. The mean follow-up duration (with echocardiography) was 29.7 months. There was no early or late death. Seven patients had anterior chordal rupture, two patients had anterior papillary muscle rupture, and one patient had both anterior chordal and anterior leaflet rupture. The median postoperative intensive care unit and hospital stays were 1 and 6 days, respectively. There were no severe postoperative complications. During follow-up, four patients exhibited trivial to mild tricuspid regurgitation, and the remaining six patients exhibited no regurgitation. Surgical treatment of TTI via either valve repair or replacement can be performed with low perioperative morbidity and mortality. Early surgery is recommended for achieving a successful valve repair and preserving right ventricular function. © 2017 Wiley Periodicals, Inc.

Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center.

PubMed

Nandipati, Kalyana C; Allamaneni, Shyam; Kakarla, Ravindra; Wong, Alfredo; Richards, Neil; Satterfield, James; Turner, James W; Sung, Kae-Jae

2011-05-01

Early identification of pneumothorax is crucial to reduce the mortality in critically injured patients. The objective of our study is to investigate the utility of surgeon performed extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax. We prospectively analysed 204 trauma patients in our level I trauma center over a period of 12 (06/2007-05/2008) months in whom EFAST was performed. The patients' demographics, type of injury, clinical examination findings (decreased air entry), CXR, EFAST and CT scan findings were entered into the data base. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. Of 204 patients (mean age--43.01+/-19.5 years, sex--male 152, female 52) 21 (10.3%) patients had pneumothorax. Of 21 patients who had pneumothorax 12 were due to blunt trauma and 9 were due to penetrating trauma. The diagnosis of pneumothorax in 204 patients demonstrated the following: clinical examination was positive in 17 patients (true positive in 13/21, 62%; 4 were false positive and 8 were false negative), CXR was positive in 16 (true positive in 15/19, 79%; 1 false positive, 4 missed and 2 CXR not performed before chest tube) patients and EFAST was positive in 21 patients (20 were true positive [95.2%], 1 false positive and 1 false negative). In diagnosing pneumothorax EFAST has significantly higher sensitivity compared to the CXR (P=0.02). Surgeon performed trauma room extended FAST is simple and has higher sensitivity compared to the chest X-ray and clinical examination in detecting pneumothorax. Published by Elsevier Ltd.

Decompression of tension pneumothoraces in Asian trauma patients: greater success with lateral approach and longer catheter lengths based on computed tomography chest wall measurements.

PubMed

Goh, S; Xu, W R; Teo, L T

2017-10-03

Our study aims to compare the anterior and lateral approaches for needle thoracostomy (NT) and determine the adequacy of catheter lengths used for NT in Asian trauma patients based on computed tomography chest wall measurements. A retrospective review of chest computed tomography scans of 583 Singaporean trauma patients during period of 2011-2015 was conducted. Four measurements of chest wall thickness (CWT) were taken at the second intercostal space, midclavicular line and fifth intercostal space, midaxillary line bilaterally. Measurements were from the superficial skin layer of the chest wall to the pleural space. Successful NT was defined radiologically as CWT ≤ 5 cm. There were 593 eligible subjects. Mean age was 49.1 years (49.1 ± 21.0). Majority were males (77.0%) and Chinese (70.2%). Mean CWT for the anterior approach was 4.04 cm (CI 3.19-4.68) on the left and 3.92 cm (CI 3.17-4.63) on the right. Mean CWT for the lateral approach was 3.52 cm (CI 2.52-4.36) on the left, and 3.62 cm (CI 3.65-4.48) on the right. Mean CWT was shorter in the lateral approach by 0.52 cm on the left and 0.30 cm on the right (p = 0.001). With a 5.0 cm catheter in the anterior approach, 925 out of 1186 sites (78.8%) will have adequate NT as compared to 98.2% with a 7.0 cm catheter. Similarly, in the lateral approach 1046 out of 1186 (88.2%) will have adequate NT as compared to 98.5% with a 7.0 cm catheter. Obese subjects had significantly higher mean CWT in both approaches (p = 0.001). There was moderate correlation between BMI and CWT in the anterior approach, r 2  = 0.529 as compared to the lateral approach, r 2  = 0.244. Needle decompression using the lateral approach or a longer catheter is more likely to succeed in Asian trauma patients. A high BMI is an independent predictor of failure of NT, especially for the anterior as compared to lateral approach.

Paediatric x-ray examinations in Rio de Janeiro

NASA Astrophysics Data System (ADS)

Azevedo, A. C. P.; Osibote, O. A.; Boechat, M. C. B.

2006-08-01

This work presents the results of a dose survey performed for paediatric patients and carried out in two large paediatric public hospitals in Rio de Janeiro city. The entrance surface dose (ESD) and the effective dose (ED) were evaluated for chest, skull, abdomen, lumbar spine, cervical spine and pelvis in antero-posterior (AP), postero-anterior (PA) and lateral (LAT) projections. For each examination, four age groups 0-1, 1-5, 5-10 and 10-15 years were studied. The DoseCal software was used to calculate these doses. Wide variations for the same type of examination and projection have been detected. These variations were evident, in Brazil, from previous work. In spite of the present results being still preliminary, they can give an idea of what paediatric ESDs are like in Brazil. Also, with respect to the entrance surface dose, some of the results are above the reference levels, which cause high ED, as well. On the other hand, the wide range of ESD reflects the disparity of radiographic techniques and demonstrates that the ALARA principle is not being applied in Brazilian hospitals and becomes a concern in terms of public health.

Contemporary management of flail chest.

PubMed

Vana, P Geoff; Neubauer, Daniel C; Luchette, Fred A

2014-06-01

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Saratzis, Nikolaos A., E-mail: saratzis@germanosnet.gr; Saratzis, Athanasios N.; Melas, Nikolaos

Purpose. Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods. Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosedmore » with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results. Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8-16 months) follow-up. Conclusions. This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.« less

[Use and versatility of titanium for the reconstruction of the thoracic wall].

PubMed

Córcoles Padilla, Juan Manuel; Bolufer Nadal, Sergio; Kurowski, Krzysztof; Gálvez Muñoz, Carlos; Rodriguez Paniagua, José Manuel

2014-02-01

Chest wall deformities/defects and chest wall resections, as well as complex rib fractures require reconstruction with various prosthetic materials to ensure the basic functions of the chest wall. Titanium provides many features that make it an ideal material for this surgery. The aim is to present our initial results with this material in several diseases. From 2008 to 2012, 14 patients were operated on and titanium was used for reconstruction of the chest wall. A total of 7 patients had chest wall tumors, 2 with sternal resection, 4 patients with chest wall deformities/defects and 3 patients with severe rib injury due to traffic accident. The reconstruction was successful in all cases, with early extubation without detecting problems in the functionality of the chest wall at a respiratory level. Patients with chest wall tumors including sternal resections were extubated in the operating room as well as the chest wall deformities. Chest trauma cases were extubated within 24h from internal rib fixation. There were no complications related to the material used and the method of implementation. Titanium is an ideal material for reconstruction of the chest wall in several clinical situations allowing for great versatility and adaptability in different chest wall reconstructions. Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: In a penetrating chest wound is a three-sided dressing or a one-way chest seal better at preventing respiratory complications?

PubMed

Walthall, Kirsten

2012-04-01

A short-cut review was carried out to establish whether the traditional three-sided dressing is better than a one-way chest seal at preventing the respiratory complications from penetrating chest trauma. Only one animal study, two guidelines and two case reports provided published evidence relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there is very little evidence, but that the one-way seals may have practical advantages, particularly in the out-of-hospital setting.

Dosimetric Quantities for Computed Tomography Examinations of Paediatric Patients on the Thoracic and Abdominal Regions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Flores-M, E.; Gamboa de Buen, I.; Buenfil, A. E.

Computed Tomography (CT) is a high dose X ray imaging procedure and its use has rapidly increased in the last two decades fueled by the development of helical CT. The aim of this study is to present values of the dosimetric quantities for CT paediatric examinations of thoracic and abdominal regions. The protocols studied were those of chest, lung-mediastine, chest-abdomen, pulmonary high resolution and mediastine-abdomen, which are the more common examinations performed at ''Hospital Infantil de Mexico Federico Gomez'' in the thoracic-abdominal region. The measurements were performed on a Siemens SOMATOM Sensation 16 CT Scanner and the equipment used wasmore » a CT pencil ionization chamber, connected to an electrometer. This system was calibrated for RQT9 CT beam quality. A PMMA head phantom with diameter of 16 cm and length of 15 cm was also used. The dosimetric quantities measured were the weighted air kerma index (C{sub w}), the volumetric dose index (C{sub vol}) and the CT air kerma-length product. It was found that the pulmonary high resolution examination presented the highest values for the C{sub w}(31.1 mGy) and C{sub vol}(11.1 mGy). The examination with the lowest values of these two quantities was the chest-abdomen protocol with 10.5 mGy for C{sub w} and 5.5 mGy for C{sub vol}. However, this protocol presented the highest value for P{sub KL,CT}(282.2 mGy cm) when considering the average clinical length of the examinations.« less

BODY SIZE-SPECIFIC EFFECTIVE DOSE CONVERSION COEFFICIENTS FOR CT SCANS.

PubMed

Romanyukha, Anna; Folio, Les; Lamart, Stephanie; Simon, Steven L; Lee, Choonsik

2016-12-01

Effective dose from computed tomography (CT) examinations is usually estimated using the scanner-provided dose-length product and using conversion factors, also known as k-factors, which correspond to scan regions and differ by age according to five categories: 0, 1, 5, 10 y and adult. However, patients often deviate from the standard body size on which the conversion factor is based. In this study, a method for deriving body size-specific k-factors is presented, which can be determined from a simple regression curve based on patient diameter at the centre of the scan range. Using the International Commission on Radiological Protection reference paediatric and adult computational phantoms paired with Monte Carlo simulation of CT X-ray beams, the authors derived a regression-based k-factor model for the following CT scan types: head-neck, head, neck, chest, abdomen, pelvis, abdomen-pelvis (AP) and chest-abdomen-pelvis (CAP). The resulting regression functions were applied to a total of 105 paediatric and 279 adult CT scans randomly sampled from patients who underwent chest, AP and CAP scans at the National Institutes of Health Clinical Center. The authors have calculated and compared the effective doses derived from the conventional age-specific k-factors with the values computed using their body size-specific k-factor. They found that by using the age-specific k-factor, paediatric patients tend to have underestimates (up to 3-fold) of effective dose, while underweight and overweight adult patients tend to have underestimates (up to 2.6-fold) and overestimates (up to 4.6-fold) of effective dose, respectively, compared with the effective dose determined from their body size-dependent factors. The authors present these size-specific k-factors as an alternative to the existing age-specific factors. The body size-specific k-factor will assess effective dose more precisely and on a more individual level than the conventional age-specific k-factors and, hence, improve awareness of the true exposure, which is important for the clinical community to understand. Published by Oxford University Press 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Continuous medical education (CME): do we need CME for paediatric environmental medicine in Europe?

PubMed

Boese-O'Reilly, Stephan

2007-10-01

The knowledge about the influence of environmental hazards on children's health is increasing enormously. European Ministers of Health and Environment, like many other stakeholders, identified the environmental hazards in Europe for the health of children as so serious, that they called for a "Children's Environment and Health Action Plan for Europe (CEHAPE)" approved in June 2004. The knowledge of paediatricians and other health care providers on children's health and environment in Europe is insufficient, due to the lack of training in environmental medicine for medical students, clinical trainees and postgraduates. Only continuous medical education in environmental medicine can help to fill this gap of knowledge and is thereby urgently needed. The World Health Organization developed a training package for health care providers for children's health and environment, containing excellent material for paediatric training events. The International Network on Children's Health, Environment and Safety (INCHES) developed additional training material for paediatricians within the Children's Health, Environment and Safety Training (CHEST) project. The German Network Children's Health and Environment offers training for paediatric doctors' assistants in primary prevention. To improve knowledge about children's health and environment at all levels in paediatric settings, greater efforts of national institutions, paediatric associations and other institutions are necessary. It is time to strengthen existing structures and to introduce, where necessary, new structures for training in environmental medicine.

Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma.

PubMed

Kasotakis, George; Hasenboehler, Erik A; Streib, Erik W; Patel, Nimitt; Patel, Mayur B; Alarcon, Louis; Bosarge, Patrick L; Love, Joseph; Haut, Elliott R; Como, John J

2017-03-01

Rib fractures are identified in 10% of all injury victims and are associated with significant morbidity (33%) and mortality (12%). Significant progress has been made in the management of rib fractures over the past few decades, including operative reduction and internal fixation (rib ORIF); however, the subset of patients that would benefit most from this procedure remains ill-defined. The aim of this project was to develop evidence-based recommendations. Population, intervention, comparison, and outcome (PICO) questions were formulated for patients with and without flail chest. Outcomes of interest included mortality, duration of mechanical ventilation (DMV), hospital and intensive care unit (ICU) length of stay (LOS), incidence of pneumonia, need for tracheostomy, and pain control. A systematic review and meta-analysis of currently available evidence was performed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. Twenty-two studies were identified and analyzed. These included 986 patients with flail chest, of whom 334 underwent rib ORIF. Rib ORIF afforded lower mortality; shorter DMV, hospital LOS, and ICU LOS; and lower incidence of pneumonia and need for tracheostomy. The data quality was deemed very low, with only three prospective randomized trials available. Analyses for pain in patients with flail chest and all outcomes in patients with nonflail chest were not feasible due to inadequate data. In adult patients with flail chest, we conditionally recommend rib ORIF to decrease mortality; shorten DMV, hospital LOS, and ICU LOS; and decrease incidence of pneumonia and need for tracheostomy. We cannot offer a recommendation for pain control, or any of the outcomes in patients with nonflail chest with currently available data. Systematic review/meta-analysis, level III.

Poland syndrome a rare congenital anomaly.

PubMed

Ibrahim, Aliyu; Ramatu, Abdallah; Helen, Akhiwu

2013-07-01

Poland syndrome is a rare congenital anomaly classically consisting of unilateral hypoplasia of the sternocostal head of the pectoralis major muscle and ipsilateral brachysyndactyly. It was first described by Alfred Poland in 1840 and may occur with different gravity. Our patient is an eight-year-old Nigerian girl with left-sided anterior chest wall defect with no detectable structural heart abnormality but presented with repeated episodes of syncopal attacks following minor trauma to the anterior chest wall.

Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax.

PubMed

Kulvatunyou, N; Erickson, L; Vijayasekaran, A; Gries, L; Joseph, B; Friese, R F; O'Keeffe, T; Tang, A L; Wynne, J L; Rhee, P

2014-01-01

Small pigtail catheters appear to work as well as the traditional large-bore chest tubes in patients with traumatic pneumothorax, but it is not known whether the smaller pigtail catheters are associated with less tube-site pain. This study was conducted to compare tube-site pain following pigtail catheter or chest tube insertion in patients with uncomplicated traumatic pneumothorax. This prospective randomized trial compared 14-Fr pigtail catheters and 28-Fr chest tubes in patients with traumatic pneumothorax presenting to a level I trauma centre from July 2010 to February 2012. Patients who required emergency tube placement, those who refused and those who could not respond to pain assessment were excluded. Primary outcomes were tube-site pain, as assessed by a numerical rating scale, and total pain medication use. Secondary outcomes included the success rate of pneumothorax resolution and insertion-related complications. Forty patients were enrolled. Baseline characteristics of 20 patients in the pigtail catheter group were similar to those of 20 patients in the chest tube group. No patient had a flail chest or haemothorax. Pain scores related to chest wall trauma were similar in the two groups. Patients with a pigtail catheter had significantly lower mean(s.d.) tube-site pain scores than those with a chest tube, at baseline after tube insertion (3.2(0.6) versus 7.7(0.6); P < 0.001), on day 1 (1.9(0.5) versus 6.2(0.7); P < 0.001) and day 2 (2.1(1.1) versus 5.5(1.0); P = 0.040). The decreased use of pain medication associated with pigtail catheter was not significantly different. The duration of tube insertion, success rate and insertion-related complications were all similar in the two groups. For patients with a simple, uncomplicated traumatic pneumothorax, use of a 14-Fr pigtail catheter is associated with reduced pain at the site of insertion, with no other clinically important differences noted compared with chest tubes. NCT01537289 (http://clinicaltrials.gov). © 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management.

PubMed

Rickard, Annette C; Vassallo, James; Nutbeam, Tim; Lyttle, Mark D; Maconochie, Ian K; Enki, Doyo G; Smith, Jason E

2018-04-28

Paediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients. An online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy. 73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation. This study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Complications in the management of bladder trauma in a third level hospital.

PubMed

Echeverría-García, Fernando Enrique; García-Perdomo, Herney Andrés; Barney, Erika

2014-05-01

To determine the frecuency of complications during the management of bladder trauma and its associated factors in a third level reference Hospital. A cross-sectional study of adult patients admitted in a reference Hospital from January 2006 to June 2011 with the diagnosis of bladder trauma. We identified demographic variables, type of trauma (blunt, penetrating), diagnostic method, associated traumatisms, management of bladder traumatism, frequency of complications and mortality. Univariate analysis was performed with frequency tables, measures of central tendency and dispersion. Similarly, bivariate analysis was performed to explore the association between variables. We used chi-square test for categorical variables and Student's t test to compare quantitative variables. We reviewed 40 medical records, which met the eligibility criteria. The median age was 27 years (range 16-;67) and 85% (34 patients) were male. Twenty-nine patients (72.5%) had penetrating injuries, being mainly firearm projectile (96.55%) and 11 patients (27.5%) blunt injuries. Most patients had intraoperative diagnosis (67.5%), while 25%, 5% and 2% were diagnosed by CT-cystography, cystoscopy and voiding cystography respectively. 70% (28 patients) had intraperitoneal bladder injuries. Of the forty patients enrolled, thirty six (90%) underwent surgery, while only four (10%) received conservative management. A total of ten patients (25%) had some type of complication. The most frequent was persistent hematuria (40%) followed by surgical site infection (30%), orchitis (20%), urinary tract infection (10%), urine leakage through the operative site, or to the peritoneal cavity (10%). No mortality was detected. On the bivariate logistic regression model type of trauma, number of injuries, performance of cystostomy, use of perivesical drainage tube, chest trauma and small bowel trauma, no association was found with the presence of complications. The frequency of complications was 25%. The presence of gross hematuria after 72 hours of trauma was found to be the most common complication. The type of trauma, performance or not performance of cystostomy, perivesical drain, presence of associated lesions in chest or small bowel were not associated with complications.

eFAST for Pneumothorax: Real-Life Application in an Urban Level 1 Center by Trauma Team Members.

PubMed

Maximus, Steven; Figueroa, Cesar; Whealon, Matthew; Pham, Jacqueline; Kuncir, Eric; Barrios, Cristobal

2018-02-01

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

Pulmonary Contusion in Mechanically Ventilated Subjects After Severe Trauma.

PubMed

Dhar, Sakshi Mathur; Breite, Matthew D; Barnes, Stephen L; Quick, Jacob A

2018-03-13

Pulmonary contusions are thought to worsen outcomes. We aimed to evaluate the effects of pulmonary contusion on mechanically ventilated trauma subjects with severe thoracic injuries and hypothesized that contusion would not increase morbidity. We conducted a single-center, retrospective review of 163 severely injured trauma subjects (injury severity score ≥ 15) with severe thoracic injury (chest abbreviated injury score ≥ 3), who required mechanical ventilation for >24 h at a verified Level 1 trauma center. Subject data were analyzed for those with radiographic documentation of pulmonary contusion and those without. Statistical analysis was performed to determine the effects of coexisting pulmonary contusion in severe thoracic trauma. Pulmonary contusion was present in 91 subjects (55.8%), whereas 72 (44.2%) did not have pulmonary contusions. Mean chest abbreviated injury score (3.54 vs 3.47, P = .53) and mean injury severity score (32.6 vs 30.2, P = .12) were similar. There was no difference in mortality (11 [12.1%] vs 9 [12.5%], P > .99) or length of stay (16.29 d vs 17.29 d, P = .60). Frequency of ventilator-associated pneumonia was comparable (43 [47.3%] vs 32 [44.4%], P = .75). Subjects with contusions were more likely to grow methicillin-sensitive Staphylococcus aureus in culture (33 vs 10, P = .004) as opposed to Pseudomonas aeruginosa in culture (6 vs 13, P = .003). Overall, no significant differences were noted in mortality, length of stay, or pneumonia rates between severely injured trauma subjects with and without pulmonary contusions. Copyright © 2018 by Daedalus Enterprises.

Tomographic aspects of penetrating thoracic trauma: injuries from firearms and other weapons

PubMed Central

de Melo, Alessandro Severo Alves; Moreira, Luiza Beatriz Melo; Pessoa, Fernanda Miraldi Clemente; Saint-Martin, Nara; Ancilotti Filho, Roger; Souza Jr., Arthur Soares; Marchiori, Edson

2017-01-01

Objective The aim of this study was to analyze the various computed tomography findings in penetrating chest trauma, as well as to determine the frequency and extent of the lesions. Material and Methods We studied the computed tomography findings from 40 cases of penetrating thoracic trauma, of which 35 (85.8%) were gunshot wounds and 5 (14.2%) were caused by another type of weapon. Results Pulmonary lesions were found in 39 cases (97.5%), manifesting as contusions in 34 cases (85%), atelectasis in 8 (20%), lacerations in 1 (2.5%) and hematomas in 1 (2.5%). Hemothorax was seen in 31 cases (77.5%), and pneumothorax was seen in 22 cases (55%). Mediastinal lesions were observed in 8 cases (20%), including mediastinal hematoma in 3 cases (7.5%), hemopericardium in 3 (7.5%), and pneumomediastinum in 2 (5%). Diaphragmatic rupture was seen in 2 cases (5%). Conclusion In patients with penetrating thoracic trauma, computed tomography of the chest is an important tool for characterizing the affected organs and evaluating the path of injury, as well as the severity and extent of the lesions. The images obtained are also useful in estimating the risk of death and determining the best therapeutic approach. PMID:29307927

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial

PubMed Central

Carver, David A; Bressan, Alexsander K; Schieman, Colin; Grondin, Sean C; Kirkpatrick, Andrew W; Lall, Rohan; McBeth, Paul B; Dunham, Michael B; Ball, Chad G

2018-01-01

Introduction Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. Methods and analysis This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. Ethics and dissemination This study has been approved by the institution’s research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. Trial registration number NCT03050502. PMID:29502092

Surgical plate fixation of multiple rib fractures: a case report.

PubMed

Mitev, Konstantin; Neziri, Dashurie; Stoicovski, Emil; Mitrev, Zan

2018-05-29

The healthcare system in developing countries is limited; particularly, medical specialties such as emergency and trauma medicine are underdeveloped. Consequently, trauma injuries sustained in traffic accidents result in chronic morbidity more often than similar cases in developed countries. Multiple rib fractures induce significant patient morbidity. Current international guidelines recommend a multidisciplinary, surgery-based treatment approach to achieve optimal clinical benefit. We admitted a 41-year-old Albanian man to our emergency department following a pedestrian-vehicle accident 5 days earlier. He presented with severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Chest radiography pointed to hypoventilated lung fields and a minor pleural effusion. Computed tomographic scans indicated displaced fractures of right lateral ribs 5 -11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment consisted of surgical fixation of ribs 7-10 using titanium reconstruction plates and cortical locking screws. The patient's clinical condition rapidly improved postoperatively. Follow-up at 6 weeks confirmed a full return to preoperative daily activities and a high quality of life. In this case report, we present a novel and promising development in the field of trauma medicine in the Republic of Macedonia. Trauma injuries can be treated via advanced multidisciplinary medical care according to international standards, allowing optimal health recovery.

Flail Chest Following Failed Cardiopulmonary Resuscitation.

PubMed

Thompson, Melissa; Langlois, Neil E I; Byard, Roger W

2017-09-01

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7-year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60-79-year-old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly. © 2017 American Academy of Forensic Sciences.

Traumatic Tricuspid Regurgitation.

PubMed

Cheng, Yan; Yao, Lei; Wu, Shengjun

2017-05-31

Traumatic tricuspid regurgitation is a rare and progressive disease. Early diagnosis and surgical valve repair are very important. A 57-year-old male was referred to our hospital with a history of blunt chest trauma. Three-dimensional echocardiography showed severe tricuspid regurgitation and demonstrated two main anterior leaflet chordaes of the tricuspid valve rupture and the whole anterior leaflet prolapsed. The diagnosis was severe tricuspid regurgitation due to leaflet chordae rupture secondary to blunt chest trauma. Surgical repair of the tricuspid valve was performed in this patient. At 3-month follow-up, the right ventricle was decreased in size with significantly improved right ventricular function. The signs and symptoms of right heart failure were relieved. In this case, 3-dimensional transthoracic echocardiography enabled fast and non-invasive evaluation of the spatial destruction of the tricuspid valve and subvalvular apparatus to assist in the planning of valve repair.

Thoracic irrigation prevents retained hemothorax: a pilot study.

PubMed

Kugler, Nathan W; Carver, Thomas W; Paul, Jasmeet S

2016-05-15

Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation. A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol. The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted. Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx. Copyright © 2016 Elsevier Inc. All rights reserved.

Missed rib fractures on evaluation of initial chest CT for trauma patients: pattern analysis and diagnostic value of coronal multiplanar reconstruction images with multidetector row CT.

PubMed

Cho, S H; Sung, Y M; Kim, M S

2012-10-01

The objective of this study was to review the prevalence and radiological features of rib fractures missed on initial chest CT evaluation, and to examine the diagnostic value of additional coronal images in a large series of trauma patients. 130 patients who presented to an emergency room for blunt chest trauma underwent multidetector row CT of the thorax within the first hour during their stay, and had follow-up CT or bone scans as diagnostic gold standards. Images were evaluated on two separate occasions: once with axial images and once with both axial and coronal images. The detection rates of missed rib fractures were compared between readings using a non-parametric method of clustered data. In the cases of missed rib fractures, the shapes, locations and associated fractures were evaluated. 58 rib fractures were missed with axial images only and 52 were missed with both axial and coronal images (p=0.088). The most common shape of missed rib fractures was buckled (56.9%), and the anterior arc (55.2%) was most commonly involved. 21 (36.2%) missed rib fractures had combined fractures on the same ribs, and 38 (65.5%) were accompanied by fracture on neighbouring ribs. Missed rib fractures are not uncommon, and radiologists should be familiar with buckle fractures, which are frequently missed. Additional coronal imagescan be helpful in the diagnosis of rib fractures that are not seen on axial images.

Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa.

PubMed

Clarke, Damian Luiz; Quazi, Muhammed A; Reddy, Kriban; Thomson, Sandie Rutherford

2011-09-01

This audit examines our total experience with penetrating thoracic trauma. It reviews all the patients who were brought alive to our surgical service and all who were taken directly to the mortuary. The group of patients who underwent emergency operation for penetrating thoracic trauma is examined in detail. A prospective trauma registry is maintained by the Pietermaritzburg Metropolitan Complex. This database was retrospectively interrogated for all patients requiring an emergency thoracic operation for penetrating injury from July 2006 till July 2009. A retrospective review of mortuary data for the same period was undertaken to identify patients with penetrating thoracic trauma who had been taken to the forensic mortuary. Over the 3-year period July 2006 to July 2009, a total of 1186 patients, 77 of whom were female, were admitted to the surgical services in Pietermaritzburg with penetrating thoracic trauma. There were 124 gunshot wounds and 1062 stab wounds. A total of 108 (9%) patients required emergency operation during the period under review. The mechanism of trauma in the operative group was stab wounds (n = 102), gunshot wound (n = 4), stab with compass (n = 1), and impalement by falling on an arrow (n = 1). Over the same period 676 persons with penetrating thoracic trauma were taken to the mortuary. There were 135 (20%) gunshot wounds of the chest in the mortuary cohort. The overall mortality for penetrating thoracic trauma was 541 (33%) of 1603 for stab wounds and 135 (52%) of 259 for gunshot wounds of the chest. Among the 541 subjects with stab wounds from the mortuary cohort, there were 206 (38%) with cardiac injuries. In the emergency operation group there were 11 (10%) deaths. In 76 patients a cardiac injury was identified. The other injuries identified were lung parenchyma bleeding (n = 12) intercostal vessels (n = 10), great vessels of the chest (n = 6), internal thoracic vessel (n = 2), and pericardial injury with no myocardial injury (n = 2). Most patients reached the hospital within 60 minutes of sustaining their injury. A subset of 12 patients had much longer delays of 12 to 24 hours. Surgical access was via median sternotomy in 56 patients and lateral thoracotomy in 52. The overall mortality for penetrating cardiac trauma in our series was 217 (76%) of 282. Penetrating thoracic trauma has a high mortality rate of 30% for subjects with stab wounds and 52% for those with gunshot wounds. Less than a quarter of patients with a penetrating cardiac injury reach the hospital alive. Of those who do and who are operated on, about 90 percent will survive. Other injuries necessitating emergency operation are lung parenchyma, intercostal vessels and internal thoracic vessels, and great vessels of the thorax. Gunshot wounds of the thorax remain more lethal than stab wounds. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Delayed diagnosis of traumatic ventricular septal defect in penetrating chest injury: small evidence on echocardiography makes big difference.

PubMed

Jeon, Kihyun; Lim, Woo-Hyun; Kang, Si-Hyuck; Cho, Iksung; Kim, Kyung-Hee; Kim, Hyung-Kwan; Kim, Yong-Jin; Sohn, Dae-Won

2010-03-01

Cardiac trauma from penetrating chest injury is a life-threatening condition. It was reported that < 10% of patients arrives at the emergency department alive. Penetrating chest injury can cause serious damage in more than 1 cardiac structure, including myocardial lacerations, ventricular septal defect (VSD), fistula between aorta and right cardiac chamber and valves. The presence of pericardial effusion (even a small amount) on the initial echocardiography might be the only clue to serious cardiac damage in the absence of definite evidence of anatomical defect in heart. We here present a case, in which clear diagnosis of VSD and pseudoaneurysmal formation was delayed a few days after penetrating chest injury due to the lack of anatomical evidence of damage.

Paediatric cervical spine injures. Nineteen years experience of a single centre.

PubMed

Ribeiro da Silva, Manuel; Linhares, Daniela; Cacho Rodrigues, Pedro; Monteiro, Eurico Lisboa; Santos Carvalho, Manuel; Negrão, Pedro; Pinto, Rui Peixoto; Neves, Nuno

2016-06-01

This observational study aims to describe pediatric C-spine injuries from a level 1 trauma centre through a period of 19 years. Clinical records of pediatric trauma patients admitted to a level 1 trauma centre between 1991 and 2009 were analyzed. Patients were stratified by age into groups A (8 or less) and B (9 to 16), and in lower (C0-C2) and upper (C3-C7) spine injuries. Several variables were studied. Seventy-five cases of C-spine injuries (nine SCIWORA) were identified. Group A included 23 patients and group B 52. In group A, skeletal injuries at the upper C-spine were more common than injuries at the lower C-spine, whereas in group B, injuries of the lower C-spine were more frequent (p = 0.035). Motor vehicle accidents were the main cause of injury (44 %); 25.3 % of patients were surgically treated. Thirty-nine patients presented neurologic deficits, 16 of which improved. The overall mortality rate was 18.7 % and significantly higher in patients with neurological damages (p < 0.001) CONCLUSIONS: This study revealed a low incidence of cervical spine injuries in the paediatric population. As in previous reports younger children mainly sustained injuries at the upper C-spine, higher incidence of spinal injuries, and higher risk of death than older children.

Hemothorax: Etiology, diagnosis, and management.

PubMed

Broderick, Stephen R

2013-02-01

Most cases of hemothorax are related to blunt or penetrating chest trauma. Criteria for surgical intervention for initial hemothorax are well defined. Appropriate management of retained hemothorax following initial trauma management is critical, and the best approach remains controversial. Spontaneous hemothorax is much less common and results from a variety of pathologic processes. This article reviews the etiology, diagnosis, and treatment of traumatic and spontaneous hemothorax in modern practice. Copyright © 2013 Elsevier Inc. All rights reserved.

Missile launch pad: an unusual consequence of airbag deployment

PubMed Central

Ronnie, Davies; Emecheta, Ikechukwu E; Kevin, Hancock

2011-01-01

Vehicle airbags significantly reduce vehicle occupant injuries and fatalities in road accidents. However, a number of injuries are recognised as being directly attributable to airbag deployment. The majority of these are blunt injuries due to the high force of airbag deployment and include ocular injuries, burns, chest trauma and, rarely, fatalities. The authors describe a case of mixed blunt ocular and penetrating facial trauma as a result of airbag deployment. PMID:22707498

Morbidity of Early Spine Surgery in the Multiply Injured Patient

DTIC Science & Technology

2014-07-31

stable’’) based on the following clinical criteria, which were adopted from previously described criteria to indicate a damage control approach to...obtained from primary source documents. Presence of any intra- cranial injury or a chest injury was identified by review of the trauma computed tomography...approach to their injuries [7, 19–21]. ‘‘Damage Control surgery’’ was first adopted by trauma surgeons to describe initial control of penetrating

Pedestrians injured by automobiles: risk factors for cervical spine injuries.

PubMed

Yanar, Hakan; Demetriades, Demetrios; Hadjizacharia, Pantelis; Hatzizacharia, Pantelis; Nomoto, Shirley; Salim, Ali; Inaba, Kenji; Rhee, Peter; Chan, Linda S

2007-12-01

Diagnosis of cervical spine injuries (CSI) in multitrauma patients, especially in the presence of head trauma, can be difficult. Identification of risk factors associated with CSI can help avoid missed or delayed diagnosis. Trauma registry study of pedestrian injuries caused by being hit by an automobile. Data abstracted for each patient included age, gender, Glasgow Coma Score on admission, Injury Severity Score, Abbreviated Injury Scale (AIS) for each body area, level of cervical spine injuries, and associated injuries. The incidence of spine injuries was derived for 4 age groups (14 years and younger, 15 to 55 years, 56 to 65 years, and older than 65 years). Logistic regression analysis was performed to identify risk factors associated with CSI. There were 8,401 pedestrian injuries caused by automobiles, and 178 patients (2.1%) had CSI. Incidence of CSI increased with age (0.3% in the age group 14 years and younger, 2.2% in the group 15 to 55 years, 3.7% in the group 56 to 65 years, and 4.4% in the group older than 65 years). Using the youngest age group (14 years and younger) as reference, relative risk of CSI in the other groups was 7.0, 12.1, and 14.2, respectively (p < 0.0001). Patients with severe head trauma (AIS > 3) were significantly more likely to have CSI than patients with less severe head injuries (AIS 3), severe chest trauma (AIS > 3), pelvic fracture, and femur fracture as independent risk factors for CSI. Incidence of CSI after injuries to pedestrians hit by automobiles increases with age and severity of head trauma. Age, severe head trauma, severe chest trauma, pelvic fracture, and femur fractures are independent predictors of CSI.

A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma.

PubMed

Chan, Yat Chun; Au-Yeung, Kwan Leong

2017-04-22

A 7-year-old boy presented to the emergency department with bilateral bloody otorrhoea after falling from his scooter. Skull base fracture was suspected. CT showed no evidence of skull base fracture but bilateral mandibular condyle and external acoustic canals fractures. We report this case to illustrate a rare possibility of bilateral external acoustic canal fracture associated with condylar fracture in trauma patients presented with bloody otorrhoea. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Paediatric utilization of a general emergency department in a developing country.

PubMed

Goh, A Y; Chan, T L; Abdel-Latiff, M E

2003-08-01

Knowledge of the spectrum and frequencies of pediatric emergencies presenting to an emergency department (ED) of individual developing countries is vital in optimizing the quality of care delivered locally. A prospective 6 wk review of all pediatric (< 18 y) attendees to an urban ED was done, with patient age, presenting complaints, diagnoses, time of arrival and disposition recorded. Complete data were available on 1172 patients, with an age range of 4 d to 18 y (mean +/- SD 6.9 +/- 5.6 y); 43% were aged < or = 4 y. The main presenting complaints were injuries (26.9%), fever (24%) and breathing difficulties (16.6%). The most common diagnosis was minor trauma (24.2%), with soft-tissue injuries predominating (80.6%). The other diagnoses were asthma (12.6%), upper respiratory infections (12.1%), other infections (12.1%) and gastroenteritis (11.8%). Equal proportions of patients were seen throughout the day. 25% of patients were admitted. Young age (< 1 y); presence of past medical history, general practitioner referrals, diagnosis of bronchiolitis and pneumonia were significantly associated with risk of admission. A wide spectrum of paediatric illnesses was seen in the ED, with an overrepresentation of young children. This supports the decision to have either a separate pediatric ED or paediatric residents on the staff. The training curricula should emphasize the management of pediatric trauma, infections and asthma. Alternatively, developing guidelines for the five most common presenting complaints would account for 82% of all attendees and could be directed towards all staff on the ED.

Paediatric empyema: a case report and literature review.

PubMed

Parsons, S J; Fenton, E; Williams, M

2005-06-01

To present a case of bilateral parapneumonic effusions in a child with Pneumococcal pneumonia and bacteraemia managed aggressively with early thoracotomies. The literature from peer reviewed journals is summarized and the different management strategies are discussed. Articles and reviews from peer reviewed journals on the management of empyema in children and adults. Staging of parapneumonic pleural effusions is difficult to assess clinically and radiologically. Most cases can be successfully managed with simple chest tube drainage, plus appropriate antibiotic therapy. However, based on the available evidence for children, thoracotomy with decortication and direct drainage may provide the most effective treatment in terms of length of hospital stay and duration of chest tube insertion, when compared with video assisted thoracoscopic surgery (VATS) or chest tube drainage, with or without intrapleural fibrinolytic therapy. More conservative approaches to treatment of empyema may be appropriate initially to avoid the cosmetic and other disadvantages of thoracotomy. However, delayed surgical drainage increases morbidity and may potentially increase mortality.

Fluid bolus therapy in critically ill children: a survey of practice among paediatric intensive care doctors in Australia and New Zealand.

PubMed

Gelbart, Ben; Schlapbach, Luregn; Ganeshalingham, Anusha; Ganu, Subodh; Erickson, Simon; Oberender, Felix; Hoq, Monsurul; Williams, Gary; George, Shane; Festa, Marino

2018-06-01

Fluid bolus therapy (FBT) is a widely used intervention in paediatric critical illness. The aim of this study was to describe the attitudes and practices towards FBT of paediatric intensive care doctors in Australia and New Zealand. An internet-based survey of paediatric intensive care doctors in Australia and New Zealand between 7 and 30 November 2016. Paediatric intensive care units with greater than 400 admissions annually. Paediatric intensive care specialists and junior medical staff. Preferences for FBT and markers of fluid responsiveness. There were 106/175 respondents (61%); 0.9% saline and 4% albumin are used frequently or almost always by 86% and 57% of respondents respectively. The preferred volume and duration were 10 mL/kg in less than 10 minutes. The highest rated markers of fluid responsiveness were heart rate and blood pressure - rated as "good" or "very good" by 75% and 58% of respondents respectively. Central venous saturations and serum lactate were the highest rated biochemical markers. The most frequently expected magnitude of change for heart rate and blood pressure was 6-15% by 89% and 76% of respondents respectively. The preferred fluid composition for sepsis, trauma, traumatic brain injury and acute lung injury was 0.9% saline, and 4% albumin for post-operative cardiac surgery. Paediatric intensive care doctors prefer 0.9% saline and 4% albumin for FBT. Heart rate and blood pressure are the most preferred markers to assess fluid responsiveness. Preferences for FBT in specific conditions exist.

[Community acquired pneumonia in children: Outpatient treatment and prevention].

PubMed

Moreno-Pérez, D; Andrés Martín, A; Tagarro García, A; Escribano Montaner, A; Figuerola Mulet, J; García García, J J; Moreno-Galdó, A; Rodrigo Gonzalo de Lliria, C; Ruiz Contreras, J; Saavedra Lozano, J

2015-12-01

There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes relate to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating CAP. In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a next second part, special situations and complicated forms will be addressed. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

Gastrointestinal injuries from blunt abdominal trauma in children.

PubMed

Ameh, E A; Nmadu, P T

2004-04-01

To determine the pattern, presentation and outcome of gastrointestinal injuries from blunt abdominal trauma in children. A retrospective study. Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Twenty one children managed for gastrointestinal injuries from blunt trauma from 1984-2002. The pattern, presentation, management and outcome of gastrointestinal injuries from blunt trauma. In the 19 year period, 1984-2002, 92 children were treated for blunt abdominal trauma, 21(23%) of who had injuries to the gastrointestinal tract. Three presenting after 24 hours had evidence of peritonitis. In six children with isolated gastrointestinal tract (GIT) injury who presented within two hours, abdominal signs were vague at initial evaluation but became marked over a few hours at repeated examination. In eight with associated intraabdominal injuries, abdominal signs were marked at initial examination and five presented with shock. Free peritoneal air was present on plain abdominal and chest radiograph in three of ten patients, dilated bowel loops in six and fluid levels in one. Diagnostic peritoneal lavage or paracentesis was positive in four patients with isolated GIT injuries and eight with associated intraabdominal injuries. There were 24 injuries in the 21 patients consisting of 15 perforations, five contusions, two seromuscular tears, and two gangrene from mesenteric injury. The small intestine was involved in 11 patients, colon six, stomach five, duodenum one and rectum one. Seven (35%) patients had associated extraabdominal injuries. Treatment consisted of simple closure of perforations, over sewing of contusions, resection and anastomosis for gangrene and repair with protective stoma for the rectal injury. One patient each developed prolonged ileus, urinary tract infection and chest infection, respectively postoperatively. Mortality was 28%, all of who had associated intraabdominal or extraabdominal injuries. Gastrointestinal injury from blunt abdominal trauma in children, though uncommon, carries a high mortality, usually from associated intraabdominal or extraabdominal injuries.

A method to detect occult pneumothorax with chest radiography.

PubMed

Matsumoto, Shokei; Kishikawa, Masanobu; Hayakawa, Koichi; Narumi, Atsushi; Matsunami, Katsutoshi; Kitano, Mitsuhide

2011-04-01

Small pneumothoraces are often not visible on supine screening chest radiographs because they develop anteriorly to the lung. These pneumothoraces are termed occult. Occult pneumothoraces account for an astonishingly high 52% to 63% of all traumatic pneumothoraces. A 19-year-old obese woman was involved in a head-on car accident. The admission anteroposterior chest radiographs were unremarkable. Because of the presence of right chest tenderness and an abrasion, we suspected the presence of a pneumothorax. Thus, we decided to take a supine oblique chest radiograph of the right side of the thorax, which clearly revealed a visceral pleural line, consistent with a diagnosis of traumatic pneumothorax. A pneumothorax may be present when a supine chest radiograph reveals either an apparent deepening of the costophrenic angle (the "deep sulcus sign") or the presence of 2 diaphragm-lung interfaces (the "double diaphragm sign"). However, in practice, supine chest radiographs have poor sensitivity for occult pneumothoraces. Oblique chest radiograph is a useful and fast screening tool that should be considered for cases of blunt chest trauma, especially when transport of critically ill patients to the computed tomographic suite is dangerous or when imminent transfer to another hospital is being arranged and early diagnosis of an occult pneumothorax is essential. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan.

PubMed

Yamagiwa, Takeshi; Morita, Seiji; Yamamoto, Rie; Seki, Tomoko; Sugimoto, Katsuhiko; Inokuchi, Sadaki

2012-01-01

Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter. We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously. The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared. The mean CWT measured in 192 males and 64 females was 3.06±1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p<0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p<0.0001). The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter. Copyright © 2010 Elsevier Ltd. All rights reserved.

Autopsy Features of Fatal Donkey Attack.

PubMed

Fogel, Lajos; Varga, Gyula; Hubay, Marta; Felszeghy, Endre; Varga, Peter; Byard, Roger W

2018-05-02

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Severe Tricuspid Regurgitation Diagnosed 13 Years after a Car Accident: A Case Report

PubMed Central

Acar, Burak; Suleymanoglu, Muhammed; Burak, Cengiz; Demirkan, Burcu Mecit; Guray, Yesim; Tufekcioglu, Omac; Aydogdu, Sinan

2015-01-01

Abstract Blunt chest traumas mostly occur due to car accidents and can cause many cardiac complications such as septal rupture, free-wall rupture, coronary artery dissection or thrombosis, heart failure, arrhythmias, and chordae and papillary muscle rupture. One of the most serious complication is tricuspid regurgitation (TR), which can be simply diagnosed by physical examination and confirmed by echocardiography. We describe a 48-year-old female patient, diagnosed with severe TR 13 years after a blunt chest trauma due to a car accident. TR was diagnosed with transthoracic echocardiography and three dimensional transthoracic echocardiography had defined the exact pathology of the tricuspid valve. The patient underwent successful surgery with bioprosthetic valve implantation and was discharged at 6th postoperative day without any complication. The patient had no problem according to the follow-up one month and six months after operation. PMID:26157464

Right massive haemothorax as the presentation of blunt cardiac rupture: the pitfall of coexisting pericardial laceration

PubMed Central

Chen, Shao-Wei; Huang, Yao-Kuang; Liao, Chien-Hung; Wang, Shang-Yu

2014-01-01

A 74-year old female was transferred to our institution because of blunt chest trauma. Chest X-ray and computed tomography (CT) revealed right haemothorax and little pericardial effusion. She was taken to the operating theatre for emergent operation because of hypotension and massive bleeding from the right-sided chest tube. Cardiopulmonary resuscitation was started during surgical exploration. There were three 1-cm lacerations actively bleeding from the right atrium and inferior vena cava junction, which were repaired successfully. Furthermore, we identified a 10 cm laceration in the right-side pleuropericardium and a communication existing between the pericardial space and the right pleural space. PMID:24218497

Right massive haemothorax as the presentation of blunt cardiac rupture: the pitfall of coexisting pericardial laceration.

PubMed

Chen, Shao-Wei; Huang, Yao-Kuang; Liao, Chien-Hung; Wang, Shang-Yu

2014-02-01

A 74-year old female was transferred to our institution because of blunt chest trauma. Chest X-ray and computed tomography (CT) revealed right haemothorax and little pericardial effusion. She was taken to the operating theatre for emergent operation because of hypotension and massive bleeding from the right-sided chest tube. Cardiopulmonary resuscitation was started during surgical exploration. There were three 1-cm lacerations actively bleeding from the right atrium and inferior vena cava junction, which were repaired successfully. Furthermore, we identified a 10 cm laceration in the right-side pleuropericardium and a communication existing between the pericardial space and the right pleural space.

Imaging of Combat-Related Thoracic Trauma - Review of Penetrating Trauma.

PubMed

Lichtenberger, John P; Kim, Andrew M; Fisher, Dane; Tatum, Peter S; Neubauer, Brian; Peterson, P Gabriel; Carter, Brett W

2018-03-01

Combat-related thoracic trauma is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries were the most common mechanisms of trauma. Imaging plays a key role in the management of combat-related thoracic trauma casualties. This review discusses the imaging manifestations of thoracic injuries from penetrating trauma, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. The assessment of radiologic findings in patients who suffer from combat-related thoracic trauma is the basis of this review article. The imaging modalities for this study include multi-detector computed tomography and chest radiography. High-velocity penetrating projectile injuries appear as hemorrhage and re-expansion pulmonary edema from the temporary cavity and a linear, blood-filled track from the permanent cavity. In cases where the projectile passes totally through the body, entrance wounds at the skin surface and tracks through the subcutaneous tissues may be the only indications of penetrating trauma. When assessing vascular injury, special attention should be paid to the right hilum in contrast-enhanced multi-detector computed tomography, as contrast is concentrated in the superior vena cava and superior cavoatrial junction may obscure small fragments. Additionally, CT angiography may show vessel disruption or extravasation of contrast distal to normal vessel location in addition to intraluminal filling defects and pseudo-aneurysms. Tension pneumopericardium may rarely complicate penetrating or blunt chest trauma. On imaging, distension of the pericardial sack by pneumopericardium and compression of the heart support the diagnosis of tension. On multi-detector computed tomography in the acute trauma setting, fluid in the pleural space should be considered hemothorax, particularly when Hounsfield units are above 35. Acutely, extravasated blood will have similar attenuation to the thoracic vasculature, whereas clotted blood will have higher values of 50-90 Hounsfield units. Combat-related thoracic trauma continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. This review of the imaging manifestations of penetrating thoracic injury during OEF and OIF focuses on key diagnostic findings for clinicians caring for combat casualties. The distinct injury pattern and atypical imaging manifestations of penetrating trauma are important to recognize early due to the acuity of this patient population and the influence of accurate diagnosis on clinical management.

[Consensus-based approach for severe paediatric asthma in routine clinical practice].

PubMed

Plaza, A M; Ibáñez, M D P; Sánchez-Solís, M; Bosque-García, M; Cabero, M J; Corzo, J L; García-Hernández, G; de la Hoz, B; Korta-Murua, J; Sánchez-Salguero, C; Torres-Borrego, J; Tortajada-Girbés, M; Valverde-Molina, J; Zapatero, L; Nieto, A

2016-02-01

Accurate identification of paediatric patients with severe asthma is essential for an adequate management of the disease. However, criteria for defining severe asthma and recommendations for control vary among different guidelines. An online survey was conducted to explore expert opinions about the definition and management of severe paediatric asthma. To reach a consensus agreement, a modified Delphi technique was used, and practice guidelines were prepared after the analysis of the results. Eleven paediatric chest disease physicians and allergy specialists with wide expertise in severe asthma responded to the survey. Consensus was reached in 50 out of 65 questions (76.92%). It was considered that a patient has severe asthma if during the previous year they have required 2 or more cycles of oral steroids, required daily treatment with medium doses of inhaled corticosteroids (with other controller medication) or high doses (with or without other controller medication), did not respond to optimised conventional treatment, or if the disease threatened the life of the patient or seriously impairs their quality of life. The definition of severe asthma may also include patients who justifiably use health resources on a regular basis, or have psychosocial or environmental factors impeding control. For monitoring, the use of questionnaires designed specifically for paediatric population, such as CAN or ACT, is recommended. As regards treatment, the use of omalizumab should be considered prior to the use of oral corticosteroids. This paper provides consensus recommendations that may be useful in the management of severe paediatric asthma. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

Pathophysiology of chest trauma.

PubMed

Calhoon, J H; Trinkle, J K

1997-05-01

Recent information indicates that there is a complex cellular and molecular generic response to injury that can lead to multi-organ failure. For many years, basic physiology and biochemistry were considered to be the systemic mechanisms to injury, but now it is known that subcellular and molecular events are the keys to unlocking the secrets of the body's response to trauma. The interaction of the endothelial cell with neutrophils and platelets to produce cytokines, free radicals, and upregulating adhesion molecules is especially significant.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial.

PubMed

Carver, David A; Bressan, Alexsander K; Schieman, Colin; Grondin, Sean C; Kirkpatrick, Andrew W; Lall, Rohan; McBeth, Paul B; Dunham, Michael B; Ball, Chad G

2018-03-03

Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. This study has been approved by the institution's research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. NCT03050502. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury.

PubMed

Helling, T S; Duke, P; Beggs, C W; Crouse, L J

1989-07-01

The prevalence and significance of cardiac injury following blunt chest trauma is largely unknown. Although electrocardiography (ECG) and creatinine phosphokinase isoenzyme (CPK-MB) determination have traditionally been used in determining cardiac injury, recent developments in two-dimensional echocardiography (ECHO) as a noninvasive diagnostic tool have led to its use in detecting structural cardiac damage following trauma. In an attempt to determine the occurrence and consequences of cardiac injury we prospectively evaluated 68 patients at one institution using ECHO, serial ECG, and serial CPK-MB determinations in the first 3 days following hospital admission. Patients were selected who had evidence of blunt chest injury on examination or by mechanism of injury. The mean age of the 68 patients was 36.3 +/- 19.6 years and the mean Injury Severity Score, 21.5 +/- 11.6. Forty-nine patients (72%) were found to have an abnormal ECHO, ECG, or CPK-MB (greater than 3%). Eighteen patients (26%) had abnormal ECHOs consisting of seven right ventricular contusions, three left ventricular contusions, three contusions of both chambers, four pericardial effusions, and one small ventricular septal defect. Only three contusions were associated with elevated CPK-MB and seven with abnormal ECGs. Abnormalities of ECG included 18 patients with S-T, T wave changes, axis shifts (11 patients), and bundle branch or hemiblocks (10 patients). No patient died or experienced serious morbidity as a result of their cardiac injury, including 12 patients who underwent surgical procedures with general anesthesia within 30 days of admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Missed rib fractures on evaluation of initial chest CT for trauma patients: pattern analysis and diagnostic value of coronal multiplanar reconstruction images with multidetector row CT

PubMed Central

Cho, S H; Sung, Y M; Kim, M S

2012-01-01

Objective The objective of this study was to review the prevalence and radiological features of rib fractures missed on initial chest CT evaluation, and to examine the diagnostic value of additional coronal images in a large series of trauma patients. Methods 130 patients who presented to an emergency room for blunt chest trauma underwent multidetector row CT of the thorax within the first hour during their stay, and had follow-up CT or bone scans as diagnostic gold standards. Images were evaluated on two separate occasions: once with axial images and once with both axial and coronal images. The detection rates of missed rib fractures were compared between readings using a non-parametric method of clustered data. In the cases of missed rib fractures, the shapes, locations and associated fractures were evaluated. Results 58 rib fractures were missed with axial images only and 52 were missed with both axial and coronal images (p=0.088). The most common shape of missed rib fractures was buckled (56.9%), and the anterior arc (55.2%) was most commonly involved. 21 (36.2%) missed rib fractures had combined fractures on the same ribs, and 38 (65.5%) were accompanied by fracture on neighbouring ribs. Conclusion Missed rib fractures are not uncommon, and radiologists should be familiar with buckle fractures, which are frequently missed. Additional coronal imagescan be helpful in the diagnosis of rib fractures that are not seen on axial images. PMID:22514102

Scandinavian guidelines for initial management of minor and moderate head trauma in children.

PubMed

Astrand, Ramona; Rosenlund, Christina; Undén, Johan

2016-02-18

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim. General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders. The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children. We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.

Evaluation of chest CT scan in low-weight children with ultralow tube voltage (70 kVp) combined with Flash scan technique

PubMed Central

Shi, Jiang W; Dai, Hong Z; Shen, Li; Ji, Yi D

2016-01-01

Objective: To assess radiation dose and image quality of chest CT examinations in low-weight children acquired at ultralow tube voltage (70 kVp) combined with Flash scan technique. Materials and methods: 30 consecutive paediatric patients (weight <20 kg) required non-contrast chest CT at 70 kVp with Flash scan mode (Group A). 30 patients for paediatric standard 80-kVp protocols with conventional spiral mode (Group B) were selected from the picture archiving and communication system. For each examination, the volume CT dose index (CTDIvol) and dose–length product (DLP), and the effective dose (adapted as 16-cm phantom) (ED16cm) were estimated. The image noise, signal-to-noise ratio (SNR), overall subjective image quality and respiratory motion artefacts were evaluated. Results: For radiation dose, CTDIvol (mGy), DLP (mGy cm) and ED16cm (mSv) of Group A were significantly lower than those of Group B [CTDIvol: 0.48 ± 0.003 mGy (Group A) vs 0.80 ± 0.005 mGy (Group B); p<0.001 DLP: 10.23 ± 1.35 mGy cm (Group A) vs 15.6 ± 2.02 mGy cm (Group B); p<0.001 ED16cm: 0.61 ± 0.91 mSv (Group A) vs 0.89 ± 0.13 mSv (Group B); p<0.001]. The mean image noise with Group A increased 28.5% (p = 0.002), and the mean SNR decreased 14.8% compared with Group B (p = 0.193). There was no statistical difference in overall subjective image quality grades, and Group A had significantly lower respiratory motion artefact grades than Group B (p < 0.001). Conclusion: Ultralow tube voltage (70 kVp) combined with the Flash scan technique of the chest can obtain images with clinically acceptable image noise and minimum respiratory motion artefacts in low-weight children, whilst reducing radiation dose significantly. Advances in knowledge: The feasibility of chest CT scan in low-weight children with ultralow tube voltage (70 kVp) combined with Flash scan technique has firstly been evaluated in our study. PMID:26781234

Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?

PubMed

Zengerink, Imme; Brink, Peter R; Laupland, Kevin B; Raber, Earl L; Zygun, Dave; Kortbeek, John B

2008-01-01

A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle. To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces. Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL. The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied. A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial.

PubMed

Nicol, Andrew J; Navsaria, Pradeep H; Hommes, Martijn; Ball, Chad G; Edu, Sorin; Kahn, Delawir

2014-03-01

To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone. The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed. A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay. Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3). SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury

PubMed Central

Karmy-Jones, Riyad; Holevar, Michele; Sullivan, Ryan J; Fleisig, Ani; Jurkovich, Gregory J

2008-01-01

BACKGROUND: Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies. OBJECTIVE: To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema. METHODS: A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score. RESULTS: A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4±26) versus those who did not (22.6±13; P=0.03). CONCLUSIONS: The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach. PMID:18716687

Analysis of Injury and Mortality Patterns in Deceased Patients with Road Traffic Injuries: An Autopsy Study.

PubMed

Pfeifer, Roman; Schick, Sylvia; Holzmann, Christopher; Graw, Matthias; Teuben, Michel; Pape, Hans-Christoph

2017-12-01

Despite improvements in prevention and rescue, mortality rates after severe blunt trauma continue to be a problem. The present study analyses mortality patterns in a representative blunt trauma population, specifically the influence of demographic, injury pattern, location and timing of death. Patients that died between 1 January 2004 and 31 December 2005 were subjected to a standardised autopsy. death from blunt trauma due to road traffic injuries (Injury Severity Score ≥ 16), patients from a defined geographical area and death on scene or in hospital. suicide, homicide, penetrating trauma and monotrauma including isolated head injury. Statistical analyses included Student's t test (parametric), Mann-Whitney U test (nonparametric) or Chi-square test. A total of 277 consecutive injured patients were included in this study (mean age 46.1 ± 23 years; 67.5% males), 40.5% of which had an ISS of 75. A unimodal distribution of mortality was observed in blunt trauma patients. The most frequently injured body regions with the highest severity were the head (38.6%), chest (26.7%), or both head and chest (11.0%). The cumulative analysis of mortality showed that several factors, such as injury pattern and regional location of collisions, also affected the pattern of mortality. The majority of patients died on scene from severe head and thoracic injuries. A homogenous distribution of death was observed after an initial peak of death on scene. Moreover, several factors such as injury pattern and regional location of collisions may also affect the pattern of mortality.

Cardiac changes after simulated behind armor blunt trauma or impact of nonlethal kinetic projectile ammunition.

PubMed

Kunz, Sebastian N; Arborelius, Ulf P; Gryth, Dan; Sonden, Anders; Gustavsson, Jenny; Wangyal, Tashi; Svensson, Leif; Rocksén, David

2011-11-01

Cardiac-related injuries caused by blunt chest trauma remain a severe problem. The aim of this study was to investigate pathophysiological changes in the heart that might arise after behind armor blunt trauma or impacts of nonlethal projectiles. Sixteen pigs were shot directly at the sternum with "Sponge Round eXact I Mpact" (nonlethal ammunition; diameter 40 mm and weight 28 g) or hard-plastic ammunition (diameter 65 mm and weight 58 g) to simulate behind armor blunt trauma. To evaluate the influence of the shot location, seven additional pigs where exposed to an oblique heart shot. Physiologic parameters, electrocardiography, echocardiogram, the biochemical marker troponin I (TnI), and myocardial injuries were analyzed. Nonlethal kinetic projectiles (101-108 m/s; 143-163 J) did not cause significant pathophysiological changes. Five of 18 pigs shot with 65-mm plastic projectiles (99-133 m/s; 284-513 J) to the front or side of the thorax died directly after the shot. No major physiologic changes could be observed in surviving animals. Animals shot with an oblique heart shot (99-106 m/s; 284-326 J) demonstrated a small, but significant decrease in saturation. Energy levels over 300 J caused increased TnI and myocardial damages in most of the pigs. This study indicates that nonlethal kinetic projectiles "eXact iMpact" does not cause heart-related damage under the examined conditions. On impact, sudden heart arrest may occur independently from the cardiac's electrical cycle. The cardiac enzyme, TnI, can be used as a reliable diagnostic marker to detect heart tissue damages after blunt chest trauma.

Changing epidemiology of trauma deaths leads to a bimodal distribution

PubMed Central

Gunst, Mark; Ghaemmaghami, Vafa; Gruszecki, Amy; Urban, Jill; Frankel, Heidi

2010-01-01

Injury mortality was classically described with a trimodal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure. We hypothesized that the development of trauma systems has improved prehospital care, early resuscitation, and critical care and altered this pattern. This population-based study of all trauma deaths in an urban county with a mature trauma system reviewed data for 678 patients (median age, 33 years; 81% male; 43% gunshot, 20% motor vehicle crashes). Deaths were classified as immediate (scene), early (in hospital, ≤4 hours from injury), or late (>4 hours after injury). Multinomial regression was used to identify independent predictors of immediate and early versus late deaths, adjusted for age, gender, race, intention, mechanism, toxicology, and cause of death. Results showed 416 (61%) immediate, 199 (29%) early, and 63 (10%) late deaths. Compared with the classical description, the percentage of immediate deaths remained unchanged, and early deaths occurred much earlier (median 52 vs 120 minutes). However, unlike the classic trimodal distribution, the late peak was greatly diminished. Intentional injuries, alcohol intoxication, asphyxia, and injuries to the head and chest were independent predictors of immediate death. Alcohol intoxication and injuries to the chest were predictors of early death, while pelvic fractures and blunt assaults were associated with late deaths. In conclusion, trauma deaths now have a predominantly bimodal distribution. Near elimination of the late peak likely represents advancements in resuscitation and critical care that have reduced organ failure. Further reductions in mortality will likely come from prevention of intentional injuries and injuries associated with alcohol intoxication. PMID:20944754

A cross-sectional study of knife injuries at a London major trauma centre.

PubMed

Pallett, J R; Sutherland, E; Glucksman, E; Tunnicliff, M; Keep, J W

2014-01-01

No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period. A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected. A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team's caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16-24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury. Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.

A cross-sectional study of knife injuries at a London major trauma centre

PubMed Central

Sutherland, E; Glucksman, E; Tunnicliff, M; Keep, JW

2014-01-01

INTRODUCTION No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period. METHODS A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected. RESULTS A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team’s caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16–24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury. CONCLUSIONS Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED. PMID:24417825

Oblique Chest X-Ray: An Alternative Way to Detect Pneumothorax.

PubMed

Tulay, Cumhur Murat; Yaldız, Sadık; Bilge, Adnan

2018-03-16

To identify occult pneumothorax with oblique chest X-ray (OCXR) in clinically suspected patients. In this retrospective study, we examined 1082 adult multitrauma patients who were admitted to our emergency service between January 2016 and January 2017. Clinical findings that suggest occult pneumothorax were rib fracture, flail chest, chest pain, subcutaneous emphysema, abrasion or ecchymosis and moderate to severe hypoxia in clinical parameters. All of these patients underwent anteroposterior chest X-ray (APCXR), but no pneumothorax could be detected. Upon this, OCXR was performed using mobile X-ray equipment. Traumatic pneumothorax was observed in 421 (38.9%) of 1082 patients. We applied OCXR to 26 multitrauma patients. Occult pneumothorax was evaluated at 22 patients (2.03%) in 1082 multitrauma patients. The 22 patients who had multitrauma occult pneumothorax on OCXR were internated at intensive care unit (ICU) and follow-up was done using OCXR and APCXR. OCXR can be an alternative imaging technique to identify occult pneumothorax in some trauma patients at emergency room and also follow period at ICU.

Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series.

PubMed

Robinson, Paul D; Blackburn, Carol; Babl, Franz E; Gamage, Lalith; Schutz, Jacquie; Nogajski, Rebecca; Dalziel, Stuart; Donald, Colin B; Druda, Dino; Krieser, David; Neutze, Jocelyn; Acworth, Jason; Lee, Mark; Ngo, Peter K

2015-10-01

Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations. Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management. 219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study. In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Factors Associated with Complications in Older Adults with Isolated Blunt Chest Trauma

PubMed Central

Lotfipour, Shahram; Kaku, Shawn K.; Vaca, Federico E.; Patel, Chirag; Anderson, Craig L.; Ahmed, Suleman S.; Menchine, Michael D.

2009-01-01

Objective: To determine the prevalence of adverse events in elderly trauma patients with isolated blunt thoracic trauma, and to identify variables associated with these adverse events. Methods: We performed a chart review of 160 trauma patients age 65 and older with significant blunt thoracic trauma, drawn from an American College of Surgeons Level I Trauma Center registry. Patients with serious injury to other body areas were excluded to prevent confounding the cause of adverse events. Adverse events were defined as acute respiratory distress syndrome or pneumonia, unanticipated intubation, transfer to the intensive care unit for hypoxemia, or death. Data collected included history, physical examination, radiographic findings, length of hospital stay, and clinical outcomes. Results: Ninety-nine patients had isolated chest injury, while 61 others had other organ systems injured and were excluded. Sixteen patients developed adverse events [16.2% 95% confidence interval (CI) 9.5–24.9%], including two deaths. Adverse events were experienced by 19.2%, 6.1%, and 28.6% of those patients 65–74, 75–84, and ≥85 years old, respectively. The mean length of stay was 14.6 days in patients with an adverse event and 5.8 days in patients without. Post hoc analysis revealed that all 16 patients with an adverse event had one or more of the following: age ≥85, initial systolic blood pressure <90 mmHg, hemothorax, pneumothorax, three or more unilateral rib fractures, or pulmonary contusion (sensitivity 100%, CI 79.4–100%; specificity 38.6%, CI 28.1–49.9%). Conclusion: Adverse events from isolated thoracic trauma in elderly patients complicate 16% of our sample. These criteria were 100% sensitive and 38.5% specific for these adverse events. This study is a first step to identifying variables that might aid in identifying patients at high risk for serious adverse events. PMID:19561823

Emergency medical services responders’ perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study

PubMed Central

Hansen, Matthew; O'Brien, Kerth; Dickinson, Caitlin; Meckler, Garth; Engle, Phil; Lambert, William; Jui, Jonathan

2017-01-01

Objective Prehospital emergency medical services (EMS) providers report anxiety as the second most common contributor to paediatric patient safety events. The objective of this study was to understand how EMS providers perceive the effect of stress and anxiety on paediatric out-of-hospital patient safety. Setting This was a nationwide study of EMS providers from 44 of 50 (88%) US states. Participants A total of 753 eligible EMS professionals, including emergency medical technicians, emergency department physicians and nurses (general and paediatric), and respiratory therapists who participate in out-of-hospital transports. Primary and secondary outcome measures Outcomes included responses to: (1) clinical situations where heightened stress or anxiety was likely to contribute to safety events, (2) aspects of these clinical situations that cause stress or anxiety and (3) how stress or anxiety may lead to paediatric safety events. Results EMS providers reported that the clinical situations where stress and anxiety were more likely to contribute to paediatric patient safety events were trauma, respiratory distress and cardiac issues. Key themes were: (1) provider sympathy or identification with children, (2) difficulty seeing an innocent child hurt and the inherent value of children and (3) insufficient exposure to paediatric emergencies. Conclusions Caring for paediatric emergencies creates unique stresses on providers that may affect patient safety. Many of the factors reported to cause provider stress and anxiety are inherent attributes of children and therefore not modifiable. Tools that support care during stressful conditions such as cognitive aids may help to mitigate anxiety in the prehospital care of children. Further research is needed to identify opportunities for and attributes of interventions. PMID:28246139

Utility of a simple lighting device to improve chest compressions learning.

PubMed

González-Calvete, L; Barcala-Furelos, R; Moure-González, J D; Abelairas-Gómez, C; Rodríguez-Núñez, A

2017-11-01

The recommendations on cardiopulmonary resuscitation (CPR) emphasize the quality of the manoeuvres, especially chest compressions (CC). Audiovisual feedback devices could improve the quality of the CC during CPR. The aim of this study was to evaluate the usefulness of a simple lighting device as a visual aid during CPR on a mannequin. Twenty-two paediatricians who attended an accredited paediatric CPR course performed, in random order, 2min of CPR on a mannequin without and with the help of a simple lighting device, which flashes at a frequency of 100 cycles per minute. The following CC variables were analyzed using a validated compression quality meter (CPRmeter ® ): depth, decompression, rate, CPR time and percentage of compressions. With the lighting device, participants increased average quality (60.23±54.50 vs. 79.24±9.80%; P=.005), percentage in target depth (48.86±42.67 vs. 72.95±20.25%; P=.036) and rate (35.82±37.54 vs. 67.09±31.95%; P=.024). A simple light device that flashes at the recommended frequency improves the quality of CC performed by paediatric residents on a mannequin. The usefulness of this CPR aid system should be assessed in real patients. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Acute flexor tendon injury following midshaft radius and ulna fractures in a paediatric patient.

PubMed

Williams, James; Wharton, Rupert; Peev, Peter; Horwitz, Maxim

2018-06-01

Delayed rupture of the extensor and flexor tendons are recognised complications of distal radius fractures. However, acute flexor tendon rupture in the context of forearm fractures is rare. A twelve-year-old female sustained midshaft fractures of the radius and ulna. Intra-operatively the flexor pollicis longus (FPL) was found to be stripped from its musculotendinous junction at the level of the fracture fragment. The ruptured tendon was repaired using a modified Krackow technique at the time of fracture fixation. The repair was protected in plaster of Paris prior to referral to the paediatric hand clinic. The patient made a full recovery. Flexor tendon injury is a rare but potentially devastating consequence of acute forearm fractures. High energy trauma, significant volar angulation of the fracture fragment and clinical signs of flexor tendon injury should raise suspicion of this injury. A high index of suspicion in conjunction with repeat clinical examination of flexor tendon function should be performed before opting for closed management or intramedullary nailing in paediatric patients.

Tuberculous osteomyelitis/arthritis of the first costo-clavicular joint and sternum

PubMed Central

Patel, Prasan; Gray, Robin R

2014-01-01

A young Somali immigrant presents with a two-year history of a large, firm, painful right anterolateral chest wall sternal mass. The patient denied any history of trauma or infection at the site and did not have a fever, erythematous lesion at the site, clubbing, or lymphadenopathy. A lateral chest radiograph demonstrated a low density mass isolated to the subcutaneous soft tissue overlying the sternum, ribs and clavicle. Computed tomography (CT) with contrast demonstrated a cystic lesion in the right anterolateral chest wall deep to the pectoralis muscle. Enhanced CT of the chest demonstrated sclerosis and destruction of the rib and costochondral joint and manubrio-sternal joint narrowing. Ultrasound-guided biopsy and aspiration returned 500 cc of purulent, cloudy yellow, foul-smelling fluid. Acid-fact bacilli stain and the nucleic acid amplification test identified and confirmed Mycobacterium tuberculosis. A diagnosis of tuberculous osteomyelitis/septic arthritis was made and antibiotic coverage for tuberculosis was initiated. PMID:25550999

Tuberculous osteomyelitis/arthritis of the first costo-clavicular joint and sternum.

PubMed

Patel, Prasan; Gray, Robin R

2014-12-28

A young Somali immigrant presents with a two-year history of a large, firm, painful right anterolateral chest wall sternal mass. The patient denied any history of trauma or infection at the site and did not have a fever, erythematous lesion at the site, clubbing, or lymphadenopathy. A lateral chest radiograph demonstrated a low density mass isolated to the subcutaneous soft tissue overlying the sternum, ribs and clavicle. Computed tomography (CT) with contrast demonstrated a cystic lesion in the right anterolateral chest wall deep to the pectoralis muscle. Enhanced CT of the chest demonstrated sclerosis and destruction of the rib and costochondral joint and manubrio-sternal joint narrowing. Ultrasound-guided biopsy and aspiration returned 500 cc of purulent, cloudy yellow, foul-smelling fluid. Acid-fact bacilli stain and the nucleic acid amplification test identified and confirmed Mycobacterium tuberculosis. A diagnosis of tuberculous osteomyelitis/septic arthritis was made and antibiotic coverage for tuberculosis was initiated.

Selective mutism due to a dog bite trauma in a 4-year-old girl: a case report

PubMed Central

2009-01-01

Introduction A child experiencing an event of threatening or catastrophic nature may experience considerable post-traumatic psychological distress. Dog bites present an important public health problem and are a frequent cause of physical trauma in children. Physicians who manage paediatric trauma may not be vigilant of the high risk of psychological stress in children exposed to a physical injury. Case presentation A 4-year-old white girl of Greek origin, with a dog-bite related trauma was admitted to the University Hospital of Crete, Greece, for surgical repair and intravenous antibiotic therapy due to extensive lesions. Exposure to the traumatic event triggered the onset of an unusual psychological response, selective mutism and acute post-traumatic stress disorder. Conclusion There is limited literature discussing the psychological effect of dog bites in children. Parents and physicians involved in pediatric physical trauma need to be more familiar with post-traumatic behavioral reactions. Awareness of the potential development of such reactions may result in early detection and effective management of children at risk. PMID:19946578

A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa.

PubMed

D'Andrea, P A; van Hoving, D J; Wood, D; Smith, W P

2014-02-01

A helicopter emergency medical service (HEMS) was established in 2005 in Richards Bay, KwaZulu-Natal, South Africa, to provide primary response and inter-facility transfers to a largely rural area with a population of 3.4 million people. To describe the first 5 years of operation of the HEMS. A chart review of all flights from 1 January 2006 to 31 December 2010 was conducted. A total of 1 429 flights were undertaken; 3 were excluded from analysis (missing folders). Most flights (88.4%) were inter-facility transfers (IFTs). Almost 10% were cancelled after takeoff. The breakdown by age was 61.9% adult, 15.1% paediatric and 21.6% neonate. The main indications for IFTs were obstetrics (34.5%), paediatrics (27.9%) and trauma (15.9%). For primary response most cases were trauma (72.9%) and obstetrics (11.3%). The median on-scene time for neonates was significantly longer (48 min, interquartile range (IQR) 35 - 64 min) than that for adults (36 min, IQR 26 - 48; p < 0.001) and paediatrics (36 min, IQR 25 - 51; p < 0.02). On-scene times for doctor-paramedic crews (45 min, IQR 27 - 50) were significantly longer than for paramedic-only crews (38 min, IQR 27 - 57; p < 0.001). The low flight-to-population ratio and primary response rate may indicate under-utilisation of the air medical service in an area with a shortage of advanced life support crews and long transport distances. Further studies on HEMSs in rural Africa are needed, particularly with regard to cost-benefit analyses, optimal activation criteria and triage systems.

Intra-Aortic Missile After Gunshot Wound to Chest: An Interesting Case of Traumatic Cardiac Injury.

PubMed

Fraser, Charles D; Goeddel, Lee; Patel, Nishant D; Azoury, Said C; Grimm, Joshua C; Sheinberg, Rosanne B; Sciortino, Christopher M

2017-05-01

Missile embolus to the heart, although uncommon, is one of the most challenging scenarios in trauma. We describe a 36-year-old man who presented with a gunshot wound to the left chest and a chest x-ray revealing a foreign body in the mediastinum. A median sternotomy was performed and an injury to the left ventricle was identified. After intraoperative echocardiography and fluoroscopy confirmed a foreign body in the aortic root, cardiopulmonary bypass was implemented. A bullet was retrieved from the noncoronary sinus of the aortic valve. Injuries to the anterior leaflet of the mitral valve and left ventricle were repaired. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

"Grief that Has No Vent in Tears, Makes Other Organs Weep." Seeking Refuge from Trauma in the Medical Setting

ERIC Educational Resources Information Center

Martin, Paddy

2012-01-01

This paper will look at work carried out with asylum-seeking families and children within a hospital paediatric setting, exploring theories that can help us to understand how highly traumatic experiences, emotionally and cognitively unprocessed, may become expressed bodily. The case examples will show how these shattered and dislocated patients…

The Cellie Coping Kit for Children with Injury: Initial feasibility, acceptability, and outcomes.

PubMed

Marsac, M L; Weiss, D; Kohser, K L; Van Allen, J; Seegan, P; Ostrowski-Delahanty, S; McGar, A; Winston, F K; Kassam-Adams, N

2018-04-15

Physical and psychological challenges can arise from paediatric injury, which can impact child health outcomes. Evidence-based resources to promote recovery are limited. The low cost, portable Cellie Coping Kit for Children with Injury provides evidence-based strategies to help children manage injury-related challenges. This study aimed to describe intervention feasibility and explore initial outcomes (learning, quality of life [QOL], and trauma symptoms). Three independent pilot studies were conducted. Child-parent dyads (n = 61) participated in the intervention; ~36% completed a 4-week follow-up assessment. Results suggested that the intervention was feasible (e.g., 95% of parents would recommend the intervention; >85% reported that it was easy to use). Over 70% of participants reported learning new skills. No statistically significant differences were detected for children's QOL or trauma symptoms preintervention to postintervention. Preliminary research suggests that the Cellie Coping Kit for Children with Injuries is a feasible, low-cost, preventive intervention, which may provide families with strategies to promote recovery from paediatric injury. Future research, including a randomized controlled trial, ought to further examine targeted long-term intervention outcomes. © 2018 John Wiley & Sons Ltd.

Comparison of ultrasonography and radiography in diagnosis of rib fractures.

PubMed

Pishbin, Elham; Ahmadi, Koorosh; Foogardi, Molood; Salehi, Maryam; Seilanian Toosi, Farrokh; Rahimi-Movaghar, Vafa

2017-08-01

Rib fractures are the most common skeletal thoracic injuries resulting from blunt chest trauma. Half of the rib fractures are not detected upon a precise physical evaluation and radiographs. Recently ultrasonography (USG) has been investigated to detect rib fractures. But based on literature the usefulness of USG varies widely. This study was conducted to investigate the role of USG in the detection of possible rib fractures in comparison with radiography. In this cross-sectional study, consecutive patients with minor blunt chest trauma and suspected rib fractures presenting in Imam Reza Hospital located in Mashhad-Iran, between April 2013 and October 2013 were assessed by USG and radiography. The radiography was performed in a posteroanterior (PA) chest projection and oblique rib view centered over the area of trauma. The time duration spent in taking USG and radiography were recorded. The prevalence and location of fractures revealed by USG and radiography were compared. Sixty-one suspected patients were assessed. The male to female ratio was 2.4:1 (43 men and 18 women) with a mean ± SD age of (44.3 ± 19.7) years. There were totally 59 rib fractures in 38 (62.3%) patients based on radiography and USG, while 23 (37.7%) patients had no diagnostic evidence of rib lesions. USG revealed 58 rib fractures in 33 (54.1%) of 61 suspected patients and radiographs revealed 32 rib fractures in 20 (32.8%) of 61 patients. A total of 58 (98.3%) rib fractures were detected by USG, whereas oblique rib view and PA chest radiography showed 27 (45.8%) and 24 (40.7%) rib fractures, respectively. The average duration of USG was (12 ± 3) min (range 7-17 min), whereas the duration of radiography was (27 ± 6) min (range 15-37 min). The kappa coefficient showed a low level of agreement between both USG and PA chest radiography (kappa coefficient = 0.28), and between USG and oblique rib view (kappa coefficient = 0.32). USG discloses more fractures than radiography in most patients presenting with suspected rib fractures. Moreover USG requires significantly less time than radiography. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Clinical and Radiologic Predictive Factors of Rib Fractures in Outpatients With Chest Pain.

PubMed

Zhang, Liang; McMahon, Colm J; Shah, Samir; Wu, Jim S; Eisenberg, Ronald L; Kung, Justin W

To identify the clinical and radiologic predictive factors of rib fractures in stable adult outpatients presenting with chest pain and to determine the utility of dedicated rib radiographs in this population of patients. Following Institutional Review Board approval, we performed a retrospective review of 339 consecutive cases in which a frontal chest radiograph and dedicated rib series had been obtained for chest pain in the outpatient setting. The frontal chest radiograph and dedicated rib series were sequentially reviewed in consensus by two fellowship-trained musculoskeletal radiologists blinded to the initial report. The consensus interpretation of the dedicated rib series was used as the gold standard. Multiple variable logistic regression analysis assessed clinical and radiological factors associated with rib fractures. Fisher exact test was used to assess differences in medical treatment between the 2 groups. Of the 339 patients, 53 (15.6%) had at least 1 rib fracture. Only 20 of the 53 (37.7%) patients' fractures could be identified on the frontal chest radiograph. The frontal chest radiograph had a sensitivity of 38% and specificity of 100% when using the rib series as the reference standard. No pneumothorax, new mediastinal widening or pulmonary contusion was identified. Multiple variable logistic regression analysis of clinical factors associated with the presence of rib fractures revealed a significant association of trauma history (odds ratio 5.7 [p < 0.05]) and age ≥40 (odds radio 3.1 [p < 0.05]). Multiple variable logistic regression analysis of radiographic factors associated with rib fractures in this population demonstrated a significant association of pleural effusion with rib fractures (odds ratio 18.9 [p < 0.05]). Patients with rib fractures received narcotic analgesia in 47.2% of the cases, significantly more than those without rib fractures (21.3%, p < 0.05). None of the patients required hospitalization. In the stable outpatient setting, rib fractures have a higher association with a history of minor trauma and age ≥40 in the adult population. Radiographic findings associated with rib fractures include pleural effusion. The frontal chest radiograph alone has low sensitivity in detecting rib fractures. The dedicated rib series detected a greater number of rib fractures. Although no patients required hospitalization, those with rib fractures were more likely to receive narcotic analgesia. Copyright © 2018 Elsevier Inc. All rights reserved.

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia.

PubMed

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21-64]) with severe trauma (initial Simplified Acute Score II = 42 [32-52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient's characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults.

Treatment for unstable pulmonary sequestration injury in patient with severe blunt trauma: A case report.

PubMed

Hiraki, Sakiko; Okada, Yohei; Arai, Yusuke; Ishii, Wataru; Iiduka, Ryoji

2017-08-01

Pulmonary sequestration is a congenital malformation characterized by nonfunctioning tissue not communicating with the tracheobronchial tree. As the blood pressure in the artery feeding the sequestrated lung tissue is higher than that in the normal pulmonary artery, the risk of massive hemorrhage in pulmonary sequestration is high. We herein present the first case of a severe blunt trauma patient with unstable pulmonary sequestration injury. The mechanism of pulmonary sequestration injury is vastly different than that of injury to normal lung. We suggest that proximal feeding artery embolization should be performed before surgical intervention in patients with massive hemorrhage of pulmonary sequestration due to severe chest trauma.

Structured Light Plethysmography (SLP): Management and follow up of a paediatric patient with pneumonia.

PubMed

Ghezzi, Michele; Tenero, Laura; Piazza, Michele; Bodini, Alessandro; Piacentini, Giorgio

2017-01-01

Structured Light Plethysmography (SLP) is a non-invasive method to study chest and abdominal movement during breathing and can identify abnormal contributions of the different regions of the chest. M.D hospitalized for pneumonia, underwent SLP and spirometry at admission (T0), after 48 hours (T1), and after one month (T2). SLP parameters showed expiratory flow limitation, information consistent with the spirometric parameters collected, and reduced motion in the area effected by pneumonia, with improvement and normalization at T1 and T2. This method gave useful information about the contribution to the respiratory movement of the lung area affected by pneumonia so we can speculate a possible use in the follow-up of children affected by pneumonia or other respiratory diseases, and who are not able to perform a spirometric test.

Utility of cervical spinal and abdominal computed tomography in diagnosing occult pneumothorax in patients with blunt trauma: Computed tomographic imaging protocol matters.

PubMed

Akoglu, Haldun; Akoglu, Ebru Unal; Evman, Serdar; Akoglu, Tayfun; Denizbasi, Arzu; Guneysel, Ozlem; Onur, Ozge; Onur, Ender

2012-10-01

Small pneumothoraces (PXs), which are not initially recognized with a chest x-ray film and diagnosed by a thoracic computed tomography (CT), are described as occult PX (OCPX). The objective of this study was to evaluate cervival spine (C-spine) and abdominal CT (ACT) for diagnosing OCPX and overt PX (OVPX). All patients with blunt trauma who presented consecutively to the emergency department during a 26-months period were included. Among all the chest CTs (CCTs) (6,155 patients) conducted during that period, 254 scans were confirmed to have a true PX. The findings in their C-spine CT and ACT were compared with the findings in CCTs. Among these patients, 254 had a diagnosis of PX confirmed with CCT. OCPXs were identified on the chest computed tomographic scan of 128 patients (70.3%), whereas OVPXs were evident in 54 patients (29.7%). Computed tomographic imaging of the C-spine was performed in 74% of patients with OCPX and 66.7% of patients with OVPX trauma. Only 45 (35.2%) cases of OCPX and 42 (77.8%) cases of OVPX were detected by C-spine CT. ACT was performed in almost all patients, and 121 (95.3%) of 127 of these correctly identified an existing OCPX. Sensitivity of C-spine CT and ACT was 35.1% and 96.5%, respectively; specificity was 100% and 100%, respectively. Almost all OCPXs, regardless of intrathoracic location, could be detected by ACT or by combining C-spine and abdominal computed tomographic screening for patients. If the junction of the first and second vertebra is used as the caudad extent, C-spine CT does not have sufficient power to diagnose more than a third of the cases. Diagnostic study, level III.

The weighty issue of obesity in paediatric respiratory medicine.

PubMed

Fitzgerald, Dominic A

2017-09-01

Some have observed that developed world is fat and getting fatter. This is even extending into the developing world, and it is important to appreciate that the consequences of childhood obesity last into adulthood and are associated with premature death. From the paediatric respiratory perspective, the deposition of excess adipose tissue in the thoraco-abdominal region begins early in life and is believed to alter diaphragm mobility and chest wall expansion, reduce lung compliance, and result in a rapid shallow breathing pattern with an increased work of breathing and reduction in maximum ventilatory capacity. This results in respiratory symptoms of exertional dyspnoea related to deconditioning which may present as exercise limitation, leading to confusion with common lung diseases such as asthma. The manifestations of the increasingly prevalent problems of overweight and obesity in young people and their interaction with common conditions of asthma and obstructive sleep apnoea will be discussed. Copyright © 2017. Published by Elsevier Ltd.

Evaluation of knowledge of students in paediatric dentistry concerning cardiopulmonary resuscitation skills in children.

PubMed

De Mauro, L M; Oliveira, L B; Bergamaschi, C De Cássia; Ramacciato, J C; Motta, R H L

2018-05-10

The study evaluated the theoretical knowledge and practical ability of students in paediatric dentistry concerning basic life support (BLS) and cardiopulmonary resuscitation (CPR) in children and babies. Seventy paediatric dentistry students answered a questionnaire and also performed a simulation of the manoeuvres of BLS and CPR on baby and child manikins. The results showed that 41 (58%) students had never received BLS training. When questioned about the correct ratio of compression and ventilation during CPR, most students answered incorrectly. For the CPR of babies in the presence of a first responder only 19 (27.1%) answered correctly (30 × 2), and for babies with two rescuers, 23 (32.8%) answered correctly (15 × 2); in relation to the correct rhythm of chest compressions, 38 (54.4%) answered incorrectly; when asked if they felt prepared to deal with a medical emergency in their dental surgeries, only 12 (17.1%) stated "yes". In the practice evaluation, 51 (73%) students who had been assessed in CPR manoeuvres for children and 55 (78%) in the manoeuvres for babies scored inadequately. The evaluated students did not have adequate knowledge about CPR in children and babies.

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

PubMed Central

Oosthuizen, GV; Sartorius, B; Keene, C; Clarke, DL

2014-01-01

Introduction Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation. PMID:25350185

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa.

PubMed

Kong, V Y; Oosthuizen, G V; Sartorius, B; Keene, C; Clarke, D L

2014-11-01

Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Dose evaluation for paediatric chest x-ray examinations in Brazil and Sudan: low doses and reliable examinations can be achieved in developing countries

NASA Astrophysics Data System (ADS)

Mohamadain, K. E. M.; da Rosa, L. A. R.; Azevedo, A. C. P.; Guebel, M. R. N.; Boechat, M. C. B.; Habani, F.

2004-03-01

Radiation protection in paediatric radiology deserves special attention since it is assumed that children are more sensitive to radiation than adults. The aim of this work is to estimate the entrance skin dose (ESD), the body organ dose (BOD) and the effective dose (E) for chest x-ray exposure of paediatric patients in five large units, three in Sudan and two in Brazil, and to compare the results obtained in both countries with each other and with other values obtained by some European countries. Two examination projections have been investigated, namely, postero-anterior (PA) and antero-posterior (AP). The age intervals considered were: 0-1 year, 1-5 years, 5-10 years and 10-15 years. The results have been obtained with the use of a software called DoseCal. Results of mean ESD for the age interval 1-5 years and AP projection are: 66 µGy (Instituto de Pediatria e Puericultura Martagão Gesteira—IPPMG Hospital), 41, 86 and 68 µGy (Instituto Fernandes Figueira—IFF Hospital), 161 µGy (Omdurman Hospital), 395 µGy (Khartoum Hospital) and 23 µGy (Ahmed Gasim Hospital). In the case of the IFF Hospital, the results refer, respectively, to rooms 1, 2 and for the six mobile equipments. The reference dose values given by the European Guidelines were exceeded in the Khartoum Hospital whilst in all the other hospitals results obtained were below CEC reference values and comparable with the results found in Sweden, Germany, Spain and Italy. The mean E for the same age interval was 11 µSv in the IPPMG, 6, 15 and 11 µSv in the IFF, respectively for rooms 1, 2 and the 6 mobiles, 25 µSv in the Omdurman Hospital, 45 µSv in the Khartoum Hospital and 3 µSv in the Ahmed Gasim Hospital. These are some examples of the large discrepancies that have been detected in this survey.

Diagnostic accuracy of oblique chest radiograph for occult pneumothorax: comparison with ultrasonography.

PubMed

Matsumoto, Shokei; Sekine, Kazuhiko; Funabiki, Tomohiro; Orita, Tomohiko; Shimizu, Masayuki; Hayashida, Kei; Kazamaki, Taku; Suzuki, Tatsuya; Kishikawa, Masanobu; Yamazaki, Motoyasu; Kitano, Mitsuhide

2016-01-01

An occult pneumothorax is a pneumothorax that is not seen on a supine chest X-ray but is detected by computed tomography scanning. However, critical patients are difficult to transport to the computed tomography suite. We previously reported a method to detect occult pneumothorax using oblique chest radiography (OXR). Several authors have also reported that ultrasonography is an effective technique for detecting occult pneumothorax. The aim of this study was to evaluate the usefulness of OXR in the diagnosis of the occult pneumothorax and to compare OXR with ultrasonography. All consecutive blunt chest trauma patients with clinically suspected pneumothorax on arrival at the emergency department were prospectively included at our tertiary-care center. The patients underwent OXR and ultrasonography, and underwent computed tomography scans as the gold standard. Occult pneumothorax size on computed tomography was classified as minuscule, anterior, or anterolateral. One hundred and fifty-nine patients were enrolled. Of the 70 occult pneumothoraces found in the 318 thoraces, 19 were minuscule, 32 were anterior, and 19 were anterolateral. The sensitivity and specificity of OXR for detecting occult pneumothorax was 61.4 % and 99.2 %, respectively. The sensitivity and specificity of lung ultrasonography was 62.9 % and 98.8 %, respectively. Among 27 occult pneumothoraces that could not be detected by OXR, 16 were minuscule and 21 could be conservatively managed without thoracostomy. OXR appears to be as good method as lung ultrasonography in the detection of large occult pneumothorax. In trauma patients who are difficult to transfer to computed tomography scan, OXR may be effective at detecting occult pneumothorax with a risk of progression.

Tactical medical skill requirements for law enforcement officers: a 10-year analysis of line-of-duty deaths.

PubMed

Sztajnkrycer, Matthew D

2010-01-01

In the absence of other data, military Tactical Combat Casualty Care (TCCC) precepts are increasingly being adapted to law enforcement needs. The purpose of this study is to better describe the nature of potentially preventable law enforcement Line-of-Duty Deaths (LODDs) occurring as a result of felonious assaults. A retrospective analysis was performed of open source data available through the US Federal Bureau of Investigation Uniform Crime Reporting (UCR) Law Enforcement Officers Killed and Assaulted (LEOKA) program for the years 1998-2007 inclusive. After applying exclusion criteria, 341 victim officers were included in the study. The most common cause of death was head trauma (n=198), followed by chest trauma (n=90). There were 123 victim officers that suffered potentially preventable deaths; the majority of these injuries involved the chest. Over the 10-year study period, only two officers (0.6%) died from isolated extremity hemorrhage. The current emphasis of TCCC on control of exsanguinating extremity hemorrhage may not meet the needs of law enforcement personnel in an environment with expedited access to well-developed trauma systems. Further study is needed to better examine the causes of preventable deaths in law enforcement officers, as well as the most appropriate law enforcement tactical medical skill set and treatment priorities.

Laryngeal fracture due to blunt trauma presenting with pneumothorax and pneumomediastinum.

PubMed

Narcı, Adnan; Embleton, Didem Baskın; Ayçiçek, Abdullah; Yücedağ, Fatih; Cetinkurşun, Salih

2011-01-01

Injuries due to traffic accidents are frequent in childhood, and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal fracture in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum and pneumothorax. A 14-year-old girl was referred for pneumomediastinum. Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. Chest tomography revealed pneumothorax and pneumomediastinum, and cranial tomography revealed maxillofacial fractures. Upper airway damage was suspected, flexible endoscopy revealed right vocal cord paralysis and cervical tomography revealed thyroid cartilage fracture. The fracture was repaired and tracheotomy was performed. She was discharged on postoperative day 6. Facial fractures were repaired in another center. Tracheotomy was removed on postoperative day 20. Her hoarseness, although decreased, still persists. Pneumomediastinum is a rare result of a laryngeal fracture and if not suspected, the fracture can easily be missed. It should be kept in mind after blunt cervical trauma with pneumomediastinum and/or pneumothorax. Direct endoscopy and cervical tomography may be necessary for the differential diagnosis. Copyright © 2011 S. Karger AG, Basel.

Ethyl pyruvate ameliorates hepatic injury following blunt chest trauma and hemorrhagic shock by reducing local inflammation, NF-kappaB activation and HMGB1 release.

PubMed

Wagner, Nils; Dieteren, Scott; Franz, Niklas; Köhler, Kernt; Mörs, Katharina; Nicin, Luka; Schmidt, Julia; Perl, Mario; Marzi, Ingo; Relja, Borna

2018-01-01

The treatment of patients with multiple trauma including blunt chest/thoracic trauma (TxT) and hemorrhagic shock (H) is still challenging. Numerous studies show detrimental consequences of TxT and HS resulting in strong inflammatory changes, organ injury and mortality. Additionally, the reperfusion (R) phase plays a key role in triggering inflammation and worsening outcome. Ethyl pyruvate (EP), a stable lipophilic ester, has anti-inflammatory properties. Here, the influence of EP on the inflammatory reaction and liver injury in a double hit model of TxT and H/R in rats was explored. Female Lewis rats were subjected to TxT followed by hemorrhage/H (60 min, 35±3 mm Hg) and resuscitation/R (TxT+H/R). Reperfusion was performed by either Ringer`s lactated solution (RL) alone or RL supplemented with EP (50 mg/kg). Sham animals underwent all surgical procedures without TxT+H/R. After 2h, blood and liver tissue were collected for analyses, and survival was assessed after 24h. Resuscitation with EP significantly improved haemoglobin levels and base excess recovery compared with controls after TxT+H/R, respectively (p<0.05). TxT+H/R-induced significant increase in alanine aminotransferase levels and liver injury were attenuated by EP compared with controls (p<0.05). Local inflammation as shown by increased gene expression of IL-6 and ICAM-1, enhanced ICAM-1 and HMGB1 protein expression and infiltration of the liver with neutrophils were also significantly attenuated by EP compared with controls after TxT+H/R (p<0.05). EP significantly reduced TxT+H/R-induced p65 activation in liver tissue. Survival rates improved by EP from 50% to 70% after TxT+H/R. These data support the concept that the pronounced local pro-inflammatory response in the liver after blunt chest trauma and hemorrhagic shock is associated with NF-κB. In particular, the beneficial anti-inflammatory effects of ethyl pyruvate seem to be regulated by the HMGB1/NF-κB axis in the liver, thereby, restraining inflammatory responses and liver injury after double hit trauma in the rat.

Diagnostic and Predictive Values of Thirst, Angiotensin II, and Vasopressin During Trauma Resuscitation

DTIC Science & Technology

2010-09-01

and plasma AVP and AT2 levels across a broader spectrum of hemorrhagic shock severity may be warranted. The authors wish to thank the medical, nursing ...301. 2. Olsson K. Central control of vasopressin release and thirst. Acta Paediatr Scand Suppl. 1983;305:36–9. Pr eh os p E m er g C ar e D ow nl oa

Surgical intervention for paediatric liver injuries is almost history - a 12-year cohort from a major Scandinavian trauma centre.

PubMed

Koyama, Tomohide; Skattum, Jorunn; Engelsen, Peder; Eken, Torsten; Gaarder, Christine; Naess, Pål Aksel

2016-11-29

Although nonoperative management (NOM) has become standard care, optimal treatment of liver injuries in children is still challenging since many of these patients have multiple injuries. Moreover, the role of angiography remains poorly defined, and a high index of suspicion of complications is warranted. This study reviews treatment and outcomes in children with liver injuries at a major Scandinavian trauma centre over a 12-year period. Patients <17 years old with liver injury admitted to Oslo University Hospital Ullevaal during the period 2002-2013 were retrospectively reviewed. Data were compiled from the institutional trauma registry and medical records. A total of 66 children were included. The majority was severely injured as reflected by a median injury severity score of 20.5 (mean 22.2). NOM was attempted in 60 (90.9%) patients and was successful in 57, resulting in a NOM success rate of 95.0% [95% CI 89.3 to 100]. Only one of the three NOM failures was liver related, occurred in the early part of the study period, and consisted in operative placement of drains for bile leak. Two (3.0%) patients underwent angiographic embolization (AE). Complications occurred in 18 (27.3% [95 % CI 16.2 to 38.3]) patients. Only 2 (3.0%) patients had liver related complications, in both cases bile leak. Six (9.1%) patients underwent therapeutic laparotomy for non-liver related injuries. Two (3.0%) patients died secondary to traumatic brain injury. This single institution paediatric liver injury cohort confirms high attempted NOM and NOM success rates even in patients with high grade injuries and multiple accompanying injuries. AE can be a useful NOM adjunct in the treatment of paediatric liver injuries, but is seldom indicated. Moreover, bile leak is the most common liver-related complication and the need for liver-related surgery is very infrequent. NOM is the treatment of choice in almost all liver injuries in children, with operative management and interventional radiology very infrequently indicated.

Experiences and needs of parents of critically injured children during the acute hospital phase: A qualitative investigation.

PubMed

Foster, Kim; Young, Alexandra; Mitchell, Rebecca; Van, Connie; Curtis, Kate

2017-01-01

Physical injury is a leading cause of death and disability among children worldwide and the largest cause of paediatric hospital admission. Parents of critically injured children are at increased risk of developing mental and emotional distress in the aftermath of child injury. In the Australian context, there is limited evidence on parent experiences of child injury and hospitalisation, and minimal understanding of their support needs. The aim of this investigation was to explore parents' experiences of having a critically injured child during the acute hospitalisation phase of injury, and to determine their support needs during this time. This multi-centre study forms part of a larger longitudinal mixed methods study investigating the experiences, unmet needs and well-being of parents of critically injured children over the two-year period following injury. This paper describes parents' experiences of having a child 0-13 years hospitalised with critical injury in one of four Australian paediatric hospitals. Semi-structured interviews were conducted with forty parents and transcribed verbatim. The data were managed using NVIVO 10 software and thematically analysed. Forty parents (26 mothers and 14 fathers) of 30 children (14 girls and 16 boys aged 1-13 years) from three Australian States participated. The majority of children were Australian born. Three main themes with sub-themes were identified: navigating the crisis of child injury; coming to terms with the complexity of child injury; and finding ways to meet the family's needs. There is a need for targeted psychological care provision for parents of critically injured children in the acute hospital phase, including psychological first aid and addressing parental blame attribution. Parents and children would benefit from the implementation of anticipatory guidance frameworks informed by a family-centred social ecological approach to prepare them for the trauma journey and for discharge. This approach could inform care delivery throughout the child injury recovery trajectory. The development and implementation of a major trauma family support coordinator in paediatric trauma centres would make a tangible difference to the care of critically injured children and their families. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Traumatic asphyxia due to blunt chest trauma: a case report and literature review

PubMed Central

2012-01-01

Introduction Crush asphyxia is different from positional asphyxia, as respiratory compromise in the latter is caused by splinting of the chest and/or diaphragm, thus preventing normal chest expansion. There are only a few cases or small case series of crush asphyxia in the literature, reporting usually poor outcomes. Case presentation We present the case of a 44-year-old Caucasian man who developed traumatic asphyxia with severe thoracic injury and mild brain edema after being crushed under heavy auto vehicle mechanical parts. He remained unconscious for an unknown time. The treatment included oropharyngeal intubation and mechanical ventilation, bilateral chest tube thoracostomies, treatment of brain edema and other supportive measures. Our patient’s outcome was good. Traumatic asphyxia is generally under-reported and most authors apply supportive measures, while the final outcome seems to be dependent on the length of time of the chest compression and on the associated injuries. Conclusion Treatment for traumatic asphyxia is mainly supportive with special attention to the re-establishment of adequate oxygenation and perfusion; treatment of the concomitant injuries might also affect the final outcome. PMID:22935547

Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases

PubMed Central

Chughtai, Talat; Ali, Syed; Sharkey, Phillip; Lins, Marcelo; Rizoli, Sandro

2009-01-01

Background Blunt diaphragmatic rupture (BDR) is a rare event and represents a diagnostic challenge. The purpose of our study was to review our experience with BDR at the Sunnybrook Health Sciences Centre (Sunnybrook), the largest trauma centre in Canada, and to highlight recent changes in the diagnosis and management of the condition. Methods We retrospectively reviewed the cases of patients with BDR who were admitted to Sunnybrook between January 1986 and December 2003 using our trauma registry. We performed Student t and Fisher exact tests to compare our findings on patients with BDR with those on the entire cohort of blunt trauma patients admitted to our centre. Results Most patients with BDR were men (64.4%) with a mean age of 42 years. Left-sided tears were most common (65.0%). Patients with BDR had a very high Injury Severity Score (38) and very high mortality (28.8%). Of those who were injured as a result of motor vehicle collisions (MVCs), a significantly greater percentage of patients in the BDR group than in the entire cohort of blunt trauma patients were drivers or front-seat passengers. Patients with BDR were also significantly less likely to be pedestrians, to have experienced a fall or to be involved in a motorcycle collision. Patients with BDR had a higher chest, abdomen, pelvis and extremity Abbreviated Injury Scale score than all blunt trauma patients in general. Most of our patients underwent laparotomy (93.3%). The most common causes of death among patients with BDR were head injury (25.0%), intra-abdominal bleeding (23.3%) and pelvic hemorrhage (18.3%). Conclusion Blunt diaphragmatic rupture is rare and difficult to diagnose; however, certain MVC characteristics along with severe associated injuries should raise the index of suspicion. These associated injuries include injuries to the head, chest (including the aorta), abdomen and pelvis. Computed tomographic angiography is essential to rule out associated aortic injury and to increase the diagnostic accuracy of BDR. PMID:19503660

The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.

PubMed

Konstantinidis, Agathoklis; Plurad, David; Barmparas, Galinos; Inaba, Kenji; Lam, Lydia; Bukur, Marko; Branco, Bernardino C; Demetriades, Demetrios

2011-09-01

A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

The future of pediatric dentistry education and curricula: a Chilean perspective.

PubMed

Mariño, Rodrigo; Ramos-Gómez, Francisco; Manton, David John; Onetto, Juan Eduardo; Hugo, Fernando; Feldens, Carlos Alberto; Bedi, Raman; Uribe, Sergio; Zillmann, Gisela

2016-07-18

A meeting was organised to consolidate a network of researchers and academics from Australia, Brazil, Chile, the UK and the USA, relating to Early Childhood Caries (ECC) and Dental Trauma (DT). As part of this meeting, a dedicated session was held on the future of paediatric dental education and curricula. Twenty-four paediatric dentistry (PD) academics, representing eight Chilean dental schools, and three international specialists (from Brazil and Latvia) participated in group discussions facilitated by five members of the ECC/DT International Collaborative Network. Data were collected from group discussions which followed themes developed as guides to identify key issues associated with paediatric dentistry education, training and research. Participants discussed current PD dental curricula in Chile, experiences in educating new cohorts of oral health care providers, and the outcomes of existing efforts in education and research in PD. They also, identified challenges, opportunities and areas in need of further development. This paper provides an introspective analysis of the education and training of PD in Chile; describes the input provided by participants into pediatric dentistry education and curricula; and sets out some key priorities for action with suggested directions to best prepare the future dental workforce to maximise oral health outcomes for children. Immediate priorities for action in paediatric dentistry in Chile were proposed.

Pitfalls in penetrating thoracic trauma (lessons we learned the hard way...).

PubMed

Degiannis, Elias; Zinn, Richard Joseph

2008-10-01

The majority of patients with penetrating thoracic trauma are managed non-operatively. Those requiring surgery usually go to theater with physiological instability. The critical condition of these patients coupled with the rarity of penetrating thoracic trauma in most European countries makes their surgical management challenging for the occasional trauma surgeon, who is usually trained as a general surgeon. Most general surgeons have a general knowledge of basic cardiothoracic operative surgery, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide him with enough armamentaria to tackle the difficult case. In this anatomical region, their operative dexterity and knowledge cannot be compared to that of their cardiothoracic colleagues, something that is taken for granted in their cardiothoracic trauma textbooks. Techniques that are considered basic and easy by the cardiothoracic surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and the pitfalls that will be encountered in cardiothoracic trauma surgery will help them to avoid intraoperative errors and improve patient outcome. The purpose of this manuscript is to highlight the commonly encountered pitfalls by trauma surgeons operating on penetrating trauma to the chest.

The selective conservative management of penetrating thoracic trauma is still appropriate in the current era.

PubMed

Kong, Victor Y; Sartorius, Benn; Clarke, Damian L

2015-01-01

Traumatic pleural collections secondary to penetrating chest trauma are generally managed by intercostal chest drainage (ICD), but these protocols were developed a few decades ago when stabs (SWs) predominated over gunshot wounds (GSWs). This study reviews the outcome of a selective conservative approach to penetrating thoracic trauma to establish if it is still appropriate in the current era. We reviewed 827 patients over a four-year period with penetrating unilateral non-cardiac wounds of the chest in order to review the efficacy of our policy and to define the differences in the spectrum of injury between SWs and GSWs. Ninety-two per cent (764/827) were males, and the median age was 24 years. Seventy-six per cent (625/827) sustained SWs and twenty-four per cent (202/827) GSWs. Chest pathologies were: pneumothorax (PTX): 362 (44%), haemothorax (HTX): 150 (18%) and haemopneumothorax (HPTX): 315 (38%). Ninety-six per cent of patients were managed non-operatively. Four per cent (36/827) were subjected to a thoracotomy [31 SWs and 5 GSWs]. No difference was observed in terms of the need for operative intervention: 5% vs. 3% [p=0.202]. PTX was seen exclusively in SWs: 58% vs. 0% and there were significantly more HPTXs seen in the GSWs: HPTX: 24% vs. 81% [p<0.001]. The median days of ICD in situ were significantly longer in GSWs compared to SWs for all pathologies. For HTX: 4.5 (interquartile range [IQR]: 3-6) vs. 3.5 (IQR: 0-5) days, p=0.001 and HPTX: 4 (IQR: 3-5) vs. 3.0 (IQR: 3-4) days, p<0.001. There were seven (15%) complications. A total of five (13%) patients died and all deaths were confined to the operative group. SWs continue to predominate over GSWs. PTXs were more commonly associated with SWs, whilst HPTX are more commonly associated with GSWs. A policy of selective conservatism is still applicable to the management of traumatic pleural collections. Copyright © 2014 Elsevier Ltd. All rights reserved.

Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study.

PubMed

DuBose, Joseph; Inaba, Kenji; Demetriades, Demetrios; Scalea, Thomas M; O'Connor, James; Menaker, Jay; Morales, Carlos; Konstantinidis, Agathoklis; Shiflett, Anthony; Copwood, Ben

2012-01-01

The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest.

PubMed

Nickerson, Terry P; Thiels, Cornelius A; Kim, Brian D; Zielinski, Martin D; Jenkins, Donald H; Schiller, Henry J

2016-01-01

Rib fractures are common after chest wall trauma. For patients with flail chest, surgical stabilization is a promising technique for reducing morbidity. Anatomical difficulties often lead to an inability to completely repair the flail chest; thus, the result is partial flail chest stabilization (PFS). We hypothesized that patients with PFS have outcomes similar to those undergoing complete flail chest stabilization (CFS). A prospectively collected database of all patients who underwent rib fracture stabilization procedures from August 2009 until February 2013 was reviewed. Abstracted data included procedural and complication data, extent of stabilization, and pulmonary function test results. Of 43 patients who underwent operative stabilization of flail chest, 23 (53%) had CFS and 20 (47%) underwent PFS. Anterior location of the fracture was the most common reason for PFS (45%). Age, sex, operative time, pneumonia, intensive care unit and hospital length of stay, and narcotic use were the same in both groups. Total lung capacity was significantly improved in the CFS group at 3 months. No chest wall deformity was appreciated on follow-up, and no patients underwent additional stabilization procedures following PFS. Despite advances in surgical technique, not all fractures are amenable to repair. There was no difference in chest wall deformity, narcotic use, or clinically significant impairment in pulmonary function tests among patients who underwent PFS compared with CFS. Our data suggest that PFS is an acceptable strategy and that extending or creating additional incisions for CFS is unnecessary.

[Characteristics of traumatic death of people in high mountains].

PubMed

Mechukaev, A A; Mechukaev, A M

2006-01-01

Lethal accidents with tourists who died of trauma in high mountains of Kabardino-Balkaria were retrospectively studied for the period from 1978 to 2003. The victims were 163 males and 17 females aged 14-72 years. Among causes of death most prevalent was a step-by-step blunt mechanical trauma as a result of falling from a great height. In such conditions the body obtains great kinetic energy causing a severe, often lethal, craniocerebral injury with destruction of the brain, blunt injury of the chest, thoracic and other organs.

Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service.

PubMed

Barker, Claire L; Weatherall, Andrew D

2014-04-01

The aim of this study was to describe the mechanism and severity of injuries in the paediatric population treated by an Australian helicopter emergency medical service and to examine the frequency and nature of interventions performed. This information is important for planning education and continuing professional development in prehospital medicine. The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, 24 h and 30-day mortality and injuries sustained. Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre.In addition, 81% of children had at least one intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%). Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children.

Evaluation of effectiveness of a paediatric simulation course in procedural skills for paediatric residents - A pilot study.

PubMed

AlShammari, Abdullah; Inayah, Aman; Afsar, Nasir Ali; Nurhussen, Akram; Siddiqui, Amna; Anwer, Muhammad Lucman; Obeidat, Sadek; Bakro, Mohammed Khaled; Abu Assale, Tawfik Samer; Almidani, Eyad; Alsonbul, Abdullah; Alhaider, Sami; Hussain, Ibrahim Bin; Khadawardi, Emad; Zafar, Muhammad

2018-02-01

To explore the effects of simulation training on paediatric residents' confidence and skills in managing advanced skills in critical care. The study was conducted at Alfaisal University, Riyadh, Saudi Arabia, from March to June 2016, and comprised junior residents in paediatrics. All paediatric residents (years 1 and 2) were recruited into two workshops, held one week apart. The first workshop covered lumbar puncture/ cerebrospinal fluid interpretation, oral intubation, bone marrow aspiration, and critical airway management. The second workshop covered chest tube insertion, pleural tap, insertion of central line, and arthrocentesis. The participants were surveyed using a 5-point Likert scale survey pre- and post-course, assessing their confidence. Their practical skills were assessed using a pre-objective structured clinical examination on the same day and post-course objective structured clinical examination a week later on selected skills. The outcome measures were: (1) pre-/post-course confidence rating, and (2) pre-/post-course objective structured clinical examination results. Data was analysed using SPSS 20. Of the 16 participants, 8(50%) were boys and 8(50%) girls. Besides, 13(81%) residents were in year-1 and 3(19%) in year-2. Median post-course confidence level ranks for all the skills were higher (p<0.05). There was no improvement in mean pre-objective structured clinical examination scores (2.31±2.66/ 7.46±3.02) and post- objective structured clinical examination scores (22.54±4.39/ 31.85±6.90) in Year 1 residents (p<0.001). Simulation course was significantly successful in improving residents' clinical skills and confidence in performing critical tasks.

[Diagnostic management in paediatric blunt abdominal trauma - a systematic review with metaanalysis].

PubMed

Schöneberg, C; Tampier, S; Hussmann, B; Lendemans, S; Waydhas, C

2014-12-01

The objective of this systematic review was to investigate the diagnostic management in paediatric blunt abdominal injuries. A literature research was performed using following sources: MEDLINE, Embase and Cochrane. Where it was possible a meta-analysis was performed. Furthermore the level of evidence for all publications was assigned. Indicators for intraabdominal injury (IAI) were elevated liver transaminases, abnormal abdominal examinations, low systolic blood pressure, reduced haematocrit and microhematuria. Detecting IAI with focused assessment with sonography for trauma (FAST) had an overall sensitivity of 56.5 %, a specificity of 94.68 %, a positive likelihood ratio of 10.63 and a negative likelihood ratio of 0.46. The accuracy was 84.02 %. Among haemodynamically unstable children the sensitivity and specificity were 100 %. The overall prevalence of IAI and negative CT was 0.19 %. The NPV of abdominal CT for diagnosing IAI was 99.8 %. The laparotomy rate in patients with isolated intraperitoneal fluid (IIF) in one location was 3.48 % and 56.52 % in patients with IIF in more than one location. FAST as an isolated tool in the diagnostics after blunt abdominal injury is very uncertain, because of the modest sensitivity. Discharging children after blunt abdominal trauma with a negative abdominal CT scan seems to be safe. When IIF is detected on CT scan, it depends on the number of locations involved. If IIF is found only in 1 location, IAI is uncommon, while IIF in two or more locations results in a high laparotomy rate. Georg Thieme Verlag KG Stuttgart · New York.

Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma

PubMed Central

Piccolo, Claudia Lucia; Galluzzo, Michele; Ianniello, Stefania; Sessa, Barbara; Trinci, Margherita

2016-01-01

Baseline ultrasound is essential in the early assessment of patients with a huge haemoperitoneum undergoing an immediate abdominal surgery; nevertheless, even with a highly experienced operator, it is not sufficient to exclude parenchymal injuries. More recently, a new ultrasound technique using second generation contrast agents, named contrast-enhanced ultrasound (CEUS) has been developed. This technique allows all the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients with low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. Several studies demonstrated its ability to detect lesions occurring in the liver, spleen, pancreas and kidneys and also to recognize active bleeding as hyperechoic bands appearing as round or oval spots of variable size. Its role seems to be really relevant in paediatric patients, thus avoiding a routine exposure to ionizing radiation. Nevertheless, CEUS is strongly operator dependent, and it has some limitations, such as the cost of contrast media, lack of panoramicity, the difficulty to explore some deep regions and the poor ability to detect injuries to the urinary tract. On the other hand, it is timesaving, and it has several advantages, such as its portability, the safety of contrast agent, the lack to ionizing radiation exposure and therefore its repeatability, which allows follow-up of those traumas managed conservatively, especially in cases of fertile females and paediatric patients. PMID:26607647

Prehospital pain management in children with traumatic injuries.

PubMed

Rutkowska, Anna; Skotnicka-Klonowicz, Grażyna

2015-05-01

Damage that arises as a result of injuries is one of the most common causes of children presenting to hospital emergency departments. The aim of the study was to assess the implementation of recommendations for prehospital pain management in injured children provided by various health care centers. A total of 7146 children aged 0 to 18 years because of injury were admitted to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz within the period of 12 months. From this group, 1493 children received prehospital emergency care from various health care centers. Health care centers provided prehospital aid to 21% of all children with injuries. Boys (60.3%) and children older than 5 years (80%) predominated among pediatric trauma cases. Prehospital emergency aid was most frequently administered to children by emergency medical services personnel (42.7%) and a primary health care physician (28.1%). Injuries of head (42.1%), neck (1.1%), chest (1.7%), abdomen (2.5%), upper (32.2%), and lower (19.9%) limbs as well as burns (5.3%) were diagnosed in pediatric patients. Indications for prehospital analgesia were found in 489 of 1493 patients (32.7%). Analgesia was administered to 159 children (32%), pain medication was not given to 223 children (46%), and in 107 cases (22%), there was a lack of information on that subject. Despite the training of medical staff, provision of analgesia for children with burns and traumatic injuries of the osteoarticular system is inadequate.

Paediatric blunt abdominal trauma - are we doing too many computed tomography scans?

PubMed

Arnold, M; Moore, S W

2013-02-14

Blunt abdominal trauma in childhood contributes significantly to both morbidity and mortality. Selective non-operative management of blunt abdominal trauma in children depends on both diagnostic and clinical factors. Computed tomography (CT) scanning is widely used to facilitate better management. Increased availability of CT may, however, result in its overuse in the management of blunt abdominal trauma in children, which carries significant radiation exposure risks. To evaluate the use and value of CT scanning in the overall management and outcome of blunt abdominal trauma in children in the Tygerberg Academic Hospital trauma unit, Parow, Cape Town, South Africa, before and after improved access to CT as a result of installation of a new rapid CT scanner in the trauma management area (previously the scanner had been 4 floors away). Patients aged 0 - 13 years who were referred with blunt abdominal trauma due to vehicle-related accidents before the introduction of the new CT scanner (group 1, n=66, November 2003 - March 2009) were compared with those seen in the 1-year period after the scanner was installed (group 2, n=37, April 2009 - April 2010). Details of clinical presentation, imaging results and their influence on management were retrospectively reviewed. A follow-up group was evaluated after stricter criteria for abdominal CT scanning (viz. prior evaluation by paediatric surgical personnel) were introduced (group 3, n=14, November 2011 - May 2012) to evaluate the impact of this clinical screening on the rate of negative scans. There were 66 patients in group 1 and 37 in group 2. An apparent increase in CT use with increased availability was accompanied by a marked increase in negative CT scans (38.9% compared with 6.2%; p<0.006). Despite a slightly higher prevalence of associated injuries in group 2, as well as a slightly longer length of hospital stay, there was a similar prevalence of intra-abdominal injuries detected in positive scans in the two groups. In addition, rates of small-bowel perforation in the two groups were similar. The rate of negative scans in group 3 was 46.2% (6/13), but all except one of these patients had a severe brain injury preventing adequate clinical evaluation of intra-abdominal injury. CT scanning for blunt abdominal trauma in children is essential in the presence of appropriate clinical indications. Ease of access probably increases availability, but the rate of negative scans may increase. Management guidelines should be in place to direct CT scanning to cases in which clinical examination and/or other modalities indicate a likelihood of intra-abdominal injury. The principle of 'as low (radiation) dose as reasonably achievable' (ALARA) should be adhered to because of the increased radiation exposure risks in children.

Post-traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research

PubMed Central

Holley, A.L.; Wilson, A.C.; Noel, M.; Palermo, T.M.

2018-01-01

Background and objective The co-occurrence of chronic pain and post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) has gained increasing research attention. Studies on associations among pain and PTSS or PTSD in youth have largely been conducted in the context of acute injury or trauma. Less is known about the risk for co-occurrence with paediatric chronic pain. In this review, we (1) propose a conceptual framework to outline factors salient during childhood that may be associated with symptom severity, co-occurrence and mutual maintenance, (2) present relevant literature on PTSS in youth with acute and chronic pain and identify research gaps and (3) provide recommendations to guide paediatric research examining shared symptomatology. Databases and data treatment Electronic databases (PubMed and Google Scholar) were used to identify relevant articles using the search terms ‘child, adolescent, paediatric, chronic pain, acute pain, post-traumatic stress symptoms and post-traumatic stress disorder’. Studies were retrieved and reviewed based on relevance to the topic. Results Our findings revealed that existing biobehavioural and ecological models of paediatric chronic pain lack attention to traumatic events or the potential development of PTSS. Paediatric studies are also limited by lack of a conceptual framework for understanding the prevalence, risk and trajectories of PTSS in youth with chronic pain. Conclusions Our new developmentally informed framework highlights individual symptoms and shared contextual factors that are important when examining potential associations among paediatric chronic pain and PTSS. Future studies should consider bidirectional and mutually maintaining associations, which will be aided by prospective, longitudinal designs. PMID:27275585

Untreated arteriovenous fistula after World War II trauma.

PubMed

Schneider, M; Creutzig, A; Alexander, K

1996-01-01

A 76-year-old-patient with severe congestive heart failure due to femoral arteriovenous fistula (AVF) after World War II trauma is presented. He was admitted to our clinic because of increasing dyspnea and vertigo during the last years. Moreover he suffered from chronic venous insufficiency on the lower limb distal of the fistula. History revealed a bullet trauma sustained 50 years ago in 1945 while riding on a train that was taken under fire. In 1973 diagnosis of traumatic AVF was first established by arteriography but the patient did not undergo surgical repair. Actual diagnostic procedure included colour Doppler imaging, chest x-ray, and echocardiography. The patient refused invasive treatment, but drug therapy of congestive heart failure was accepted.

[Polytrauma with tension pneumothorax with inserted chest tube].

PubMed

Genzwürker, H V; Volz, A; Isselhorst, C; Gieser, R; Neufang, T; Roth, H; Birmelin, M; Kerger, H

2005-12-01

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.

Development and validation of a paediatric long-bone fracture classification. A prospective multicentre study in 13 European paediatric trauma centres

PubMed Central

2011-01-01

Background The aim of this study was to develop a child-specific classification system for long bone fractures and to examine its reliability and validity on the basis of a prospective multicentre study. Methods Using the sequentially developed classification system, three samples of between 30 and 185 paediatric limb fractures from a pool of 2308 fractures documented in two multicenter studies were analysed in a blinded fashion by eight orthopaedic surgeons, on a total of 5 occasions. Intra- and interobserver reliability and accuracy were calculated. Results The reliability improved with successive simplification of the classification. The final version resulted in an overall interobserver agreement of κ = 0.71 with no significant difference between experienced and less experienced raters. Conclusions In conclusion, the evaluation of the newly proposed classification system resulted in a reliable and routinely applicable system, for which training in its proper use may further improve the reliability. It can be recommended as a useful tool for clinical practice and offers the option for developing treatment recommendations and outcome predictions in the future. PMID:21548939

A stratified response system for the emergency management of the severely injured.

PubMed

Lloyd, D A; Patterson, M; Robson, J; Phillips, B

2001-01-01

A decade ago, there were justifiable criticisms of the delivery of emergency care for injured patients in accident and emergency departments in the UK. To address this, a trauma management system was developed in 1991 at Alder Hey Hospital, Liverpool. This includes a trauma team, communication system, management guidelines and quality assurance. On admission to the accident and emergency department, injured patients are triaged to one of three levels of injury severity, and a multidisciplinary team lead by a paediatric surgeon or senior accident and emergency department physician is activated. The level of injury severity determines the composition of the trauma team. A care pathway based on ATLS/APLS principles has been developed. The response process as well patient management are documented and reviewed at a monthly audit meeting. Currently, more than 80% of eligible patients are managed using the trauma system, with an over-triage rate of about 25%. Regular modifications to the trauma system since its inception in 1991 have resulted in an efficient and effective management structure. Stratification of the trauma response has minimised unnecessary use of the multidisciplinary trauma team and ensures that mobilisation and use of hospital staff and resources are tailored to the needs of the injured patient. Although developed in a specialist children's hospital, the system could be adapted for any acute hospital.

On the Alert: Preparing for Medical Emergencies in Schools

ERIC Educational Resources Information Center

Mahoney, Dan

2012-01-01

Medical emergencies can happen in any school at any time. They can be the result of preexisting health problems, accidents, violence, unintentional actions, natural disasters, and toxins. Premature deaths in schools from sudden cardiac arrest, blunt trauma to the chest, firearm injuries, asthma, head injuries, drug overdose, allergic reactions,…

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia

PubMed Central

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

Object We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. Methods We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Results Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21–64]) with severe trauma (initial Simplified Acute Score II = 42 [32–52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient’s characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Conclusions Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults. PMID:29261721

Clavicle fracture with intrathoracic displacement.

PubMed

Lohse, Grant R; Lee, Donald H

2013-08-01

Clavicle fractures are common, and most are isolated injuries. Injury to the nearby subclavian vessels and brachial plexus have classically been described as potential complications of clavicle fractures. However, in the setting of a substantially displaced clavicle fracture, concomitant thoracic trauma is relatively frequent. Injury to the thorax can be difficult to identify on physical examination, and advanced imaging modalities may be required for diagnosis. The evaluation, workup, and management of a patient with intrathoracic displacement of a clavicle fracture are described. Despite the significant fracture displacement and associated pneumothorax, the injury severity was not clinically obvious. Imaging, including a screening chest radiograph and subsequent axial computed tomography, played an important role in diagnosis and management. The patient underwent successful open reduction and plate fixation. A thoracostomy tube was not required at any point during the hospitalization. The patient recovered uneventfully and returned to full work duty by 3 months postoperatively. Including the current report, only 3 cases of intrathoracic displacement of the clavicle have been published in the English literature. All involved fractures of the middle third of the clavicle. The severity of displacement was not obvious in any patient, and diagnosis was dependent on additional imaging. Given the frequency of associated chest trauma and limitations of physical examination, chest radiography should be considered in the evaluation of patients with substantially displaced clavicle fractures. Copyright 2013, SLACK Incorporated.

Do we really need new medical information about the Turin Shroud?

PubMed

Bevilacqua, M; Fanti, G; D'Arienzo, M; De Caro, R

2014-02-01

Image processing of the Turin Shroud (TS) shows that the Man represented in it has undergone an under glenoidal dislocation of the humerus on the right side and lowering of the shoulder, and has a flattened hand and enophthalmos; conditions that have not been described before, despite several studies on the subject. These injuries indicate that the Man suffered a violent blunt trauma to the neck, chest and shoulder from behind, causing neuromuscular damage and lesions of the entire brachial plexus. The posture of the left claw-hand is indicative of an injury of the lower brachial plexus, as is the crossing of the hands on the pubis, not above the pubis as it would normally be, and are related to traction of the limbs as a result of the nailing to the patibulum. The disappearance of the thumbprints is because of entrainment of the flexor pollicis longus tendons while the nails were driven through the wrists. The blunt chest trauma, which resulted in the body falling forwards, was the direct cause of a lung contusion and haemothorax, confirmed by the post-mortem leakage of clots and serum from the chest caused by the stabbing with the spear, and was a likely cause of cardiac contusion. All the evidence is in favour of the hypothesis that the TS Man is Jesus of Nazareth. Copyright © 2013 Elsevier Ltd. All rights reserved.

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

PubMed

Guise, Jeanne-Marie; Hansen, Matthew; O'Brien, Kerth; Dickinson, Caitlin; Meckler, Garth; Engle, Phil; Lambert, William; Jui, Jonathan

2017-02-28

Prehospital emergency medical services (EMS) providers report anxiety as the second most common contributor to paediatric patient safety events. The objective of this study was to understand how EMS providers perceive the effect of stress and anxiety on paediatric out-of-hospital patient safety. This was a nationwide study of EMS providers from 44 of 50 (88%) US states. A total of 753 eligible EMS professionals, including emergency medical technicians, emergency department physicians and nurses (general and paediatric), and respiratory therapists who participate in out-of-hospital transports. Outcomes included responses to: (1) clinical situations where heightened stress or anxiety was likely to contribute to safety events, (2) aspects of these clinical situations that cause stress or anxiety and (3) how stress or anxiety may lead to paediatric safety events. EMS providers reported that the clinical situations where stress and anxiety were more likely to contribute to paediatric patient safety events were trauma, respiratory distress and cardiac issues. Key themes were: (1) provider sympathy or identification with children, (2) difficulty seeing an innocent child hurt and the inherent value of children and (3) insufficient exposure to paediatric emergencies. Caring for paediatric emergencies creates unique stresses on providers that may affect patient safety. Many of the factors reported to cause provider stress and anxiety are inherent attributes of children and therefore not modifiable. Tools that support care during stressful conditions such as cognitive aids may help to mitigate anxiety in the prehospital care of children. Further research is needed to identify opportunities for and attributes of interventions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance?

PubMed

Poropat, F; Heinz, P; Barbi, E; Ventura, A

2017-03-08

To compare paediatric Emergency Department (ED) attendances and admission outcomes in two European hospitals with different paediatric primary care set-up. This is a retrospective prevalence study comparing all paediatric ED attendances during calendar years 2013 in two EDs with similar catchment area: one in Italy (Trieste) where paediatric primary care is provided by office paediatricians, the other, in the UK (Cambridge), where paediatric primary care is provided by general practitioners. Data on reason for presentation, discharge diagnosis and admission rate were collected and sub-group analysis for specific age groups (<1 year, 1-4 years, 5-15 years) was performed. Over 12 months, 20.331 children (0-15 years old) were seen in Cambridge and 18.646 in Trieste, with a very similar age distribution in both centres, except for the youngest age group: the percentage of infants seen in comparison with the total number of children attending ED was 1/3 higher in England than in Italy (15.4% vs 11.4%). The reasons for attendance were similar: under 1 year of age, the chief complaints were fever, breathing difficulties and gastrointestinal problems while in the older age groups trauma represented the commonest reason. Among discharge diagnoses, no differences were found between the two hospitals, except for faltering growth and "well child", more frequently diagnosed in English children under 5 years. The proportion of admissions was three times higher in Cambridge (14.1% vs 4.8%) with most children being admitted for infectious diseases. ED attendances in infants are more common in a primary care setting provided by general practicioner and, moreover, admission rates in all age groups are 1/3 reduced by primary care based paediatricians. Due to the methodological limits of this study, it isn't possible to evaluate whether these results depend only on paediatric primary care set-up or be determined by other confounding factors. New studies are needed to confirm this preliminary evidence.

[Endovascular interventions for multiple trauma].

PubMed

Kinstner, C; Funovics, M

2014-09-01

In recent years interventional radiology has significantly changed the management of injured patients with multiple trauma. Currently nearly all vessels can be reached within a reasonably short time with the help of specially preshaped catheters and guide wires to achieve bleeding control of arterial und venous bleeding. Whereas bleeding control formerly required extensive open surgery, current interventional methods allow temporary vessel occlusion (occlusion balloons), permanent embolization and stenting. In injured patients with multiple trauma preinterventional procedural planning is performed with the help of multidetector computed tomography whenever possible. Interventional radiology not only allows minimization of therapeutic trauma but also a considerably shorter treatment time. Interventional bleeding control has developed into a standard method in the management of vascular trauma of the chest and abdomen as well as in vascular injuries of the upper and lower extremities when open surgical access is associated with increased risk. Additionally, pelvic trauma, vascular trauma of the superior thoracic aperture and parenchymal arterial lacerations of organs that can be at least partially preserved are primarily managed by interventional methods. In an interdisciplinary setting interventional radiology provides a safe and efficient means of rapid bleeding control in nearly all vascular territories in addition to open surgical access.

Use of the omentum in chest-wall reconstruction

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fix, R.J.; Vasconez, L.O.

1989-10-01

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on bothmore » sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.« less

Performance of advanced trauma life support procedures in microgravity

NASA Technical Reports Server (NTRS)

Campbell, Mark R.; Billica, Roger D.; Johnston, Smith L 3rd; Muller, Matthew S.

2002-01-01

BACKGROUND: Medical operations on the International Space Station will emphasize the stabilization and transport of critically injured personnel and so will need to be capable of advanced trauma life support (ATLS). METHODS: We evaluated the ATLS invasive procedures in the microgravity environment of parabolic flight using a porcine animal model. Included in the procedures evaluated were artificial ventilation, intravenous infusion, laceration closure, tracheostomy, Foley catheter drainage, chest tube insertion, peritoneal lavage, and the use of telemedicine methods for procedural direction. RESULTS: Artificial ventilation was performed and appeared to be unaltered from the 1-G environment. Intravenous infusion, laceration closure, percutaneous dilational tracheostomy, and Foley catheter drainage were achieved without difficulty. Chest tube insertion and drainage were performed with no more difficulty than in the 1-G environment due to the ability to restrain patient, operator and supplies. A Heimlich valve and Sorenson drainage system were both used to provide for chest tube drainage collection with minimal equipment, without the risk of atmospheric contamination, and with the capability to auto-transfuse blood drained from a hemothorax. The use of telemedicine in chest tube insertion was demonstrated to be useful and feasible. Peritoneal lavage using a percutaneous technique, although requiring less training to perform, was found to be dangerous in weightlessness due to the additional pressure of the bowel on the anterior abdominal wall creating a high risk of bowel perforation. CONCLUSIONS: The performance of ATLS procedures in microgravity appears to be feasible with the exception of diagnostic peritoneal lavage. Minor modifications to equipment and techniques are required in microgravity to effect surgical drainage in the presence of altered fluid dynamics, to prevent atmospheric contamination, and to provide for the restraint requirements. A parabolic simulation system was developed for equipment and procedure verification, physiological research, and possible crew medical officer training in the future.

Tension pneumopericardium following suicidal stab wounds to the chest.

PubMed

Heimer, Jakob; Bolliger, Stephan A; Thali, Michael J; Schweitzer, Wolf

2017-12-01

Pneumopericardium (PPC) and Tension Pneumopericardium (TPPC) refer to collections of gas in the pericardial cavity, the latter resulting in air tamponade and cardiac compromise. Following penetrating chest injuries, PPC and TPPC appear to be uncommon findings associated with a high mortality and correlated with other thoracic trauma. Diagnosis of PPC and TPPC is difficult relying on conventional autopsy alone, while postmortem computed tomography (PMCT) shows a high sensitivity for the detection of internal gas collections. Possibly due to difficulty in detection, PPC and TPPC have not been discussed from a forensic point of view and many lethal cases of PPC and TPPC might have been missed in medicolegal investigations. In this report, we present a case with suicidal, penetrating stab wounds to the chest resulting in a TPPC with lethal air tamponade documented by PMCT.

App-based serious gaming for training of chest tube insertion: study protocol for a randomized controlled trial.

PubMed

Friedrich, Mirco; Bergdolt, Christian; Haubruck, Patrick; Bruckner, Thomas; Kowalewski, Karl-Friedrich; Müller-Stich, Beat Peter; Tanner, Michael C; Nickel, Felix

2017-02-06

Chest tube insertion is a standard intervention for management of various injuries of the thorax. Quick and accurate execution facilitates efficient therapy without further complications. Here, we propose a new training concept comprised of e-learning elements as well as continuous rating using an objective structured assessment of technical skills (OSATS) tool. The study protocol is presented for a randomized trial to evaluate e-learning with app-based serious gaming for chest drain insertion. The proposed randomized trial will be carried out at the Department of Orthopedics and Traumatology at Heidelberg University in the context of regular curricular teaching for medical students (n = 90, 3rd to 6th year). The intervention group will use e-learning with the serious gaming app Touch Surgery (TM) for chest drain insertion, whereas the control group uses serious gaming for an unrelated procedure. Primary endpoint is operative performance of chest drain insertion in a porcine cadaveric model according to OSATS. The randomized trial will help determine the value of e-learning with the serious gaming app Touch Surgery (TM) for chest drain insertion by using the OSATS score. The study will improve surgical training for trauma situations. Trial Registration Number, DRKS00009994 . Registered on 27 May 2016.

Utility of Chest Computed Tomography after a "Normal" Chest Radiograph in Patients with Thoracic Stab Wounds.

PubMed

Nguyen, Brian M; Plurad, David; Abrishami, Sadaf; Neville, Angela; Putnam, Brant; Kim, Dennis Y

2015-10-01

Chest computed tomography (CCT) is used to screen for injuries in hemodynamically stable patients with penetrating injury. We aim to determine the incidence of missed injuries detected on CCT after a negative chest radiograph (CXR) in patients with thoracic stab wounds. A 10-year retrospective review of a Level I trauma center registry was performed on patients with thoracic stab wounds. Patients who were hemodynamically unstable or did not undergo both CXR and CCT were excluded. Patients with a negative CXR were evaluated to determine if additional findings were diagnosed on CCT. Of 386 patients with stab wounds to the chest, 154 (40%) underwent both CXR and CCT. One hundred and fifteen (75%) had a negative screening CXR. CCT identified injuries in 42 patients (37%) that were not seen on CXR. Pneumothorax and/or hemothorax occurred in 40 patients (35%), of which 14 patients underwent tube thoracostomy. Two patients had hemopericardium on CCT and both required operative intervention. Greater than one-third of patients with a normal screening CXR were found to have abnormalities on CCT. Future studies comparing repeat CXR to CCT are required to further define the optimal diagnostic strategy in patients with stab wounds to chest after normal screening CXR.

Analysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms.

PubMed

Alvarez, Bruno Durante; Razente, Danilo Mardegam; Lacerda, Daniel Augusto Mauad; Lother, Nicole Silveira; VON-Bahten, Luiz Carlos; Stahlschmidt, Carla Martinez Menini

2016-01-01

to analyze the epidemiological profile and mortality associated with the Revised Trauma Score (RTS) in trauma victims treated at a university hospital. we conducted a descriptive, cross-sectional study of trauma protocols (prospectively collected) from December 2013 to February 2014, including trauma victims admitted in the emergency room of the Cajuru University Hospital. We set up three groups: (G1) penetrating trauma to the abdomen and chest, (G2) blunt trauma to the abdomen and chest, and (G3) traumatic brain injury. The variables we analyzed were: gender, age, day of week, mechanism of injury, type of transportation, RTS, hospitalization time and mortality. we analyzed 200 patients, with a mean age of 36.42 ± 17.63 years, and 73.5% were male. The mean age was significantly lower in G1 than in the other groups (p <0.001). Most (40%) of the visits occurred on weekends and the most common pre-hospital transport service (58%) was the SIATE (Emergency Trauma Care Integrated Service). The hospital stay was significantly higher in G1 compared with the other groups (p <0.01). Regarding mortality, there were 12%, 1.35% and 3.95% of deaths in G1, G2 and G3, respectively. The median RTS among the deaths was 5.49, 7.84 and 1.16, respectively, for the three groups. the majority of patients were young men. RTS was effective in predicting mortality in traumatic brain injury, however failing to predict it in patients suffering from blunt and penetrating trauma. analisar o perfil epidemiológico e a mortalidade associada ao escore de trauma revisado (RTS) em vítimas de trauma atendidas em um hospital universitário. estudo transversal descritivo de protocolos de trauma (coletados prospectivamente) de dezembro de 2013 a fevereiro de 2014, incluindo vítimas de trauma admitidas na sala de emergência do Hospital Universitário Cajuru. Três grupos foram criados: (G1) trauma penetrante em abdome e tórax, (G2) trauma contuso em abdome e tórax, e (G3) trauma cranioencefálico. As variáveis analisadas foram: sexo, idade, dia da semana, mecanismo de trauma, tipo de transporte, RTS, tempo de internamento e mortalidade. analisou-se 200 pacientes, com média de idade de 36,42 ± 17,63 anos, sendo 73,5% do sexo masculino. A média de idade no G1 foi significativamente menor do que nos demais grupos (p <0,001). A maioria (40%) dos atendimentos ocorreu nos finais de semana e o serviço de transporte pré-hospitalar mais frequente (58%) foi o SIATE (Serviço Integrado de Atendimento ao Trauma em Emergência). O tempo de internamento foi significativamente maior no G1, em comparação aos demais grupos (p <0,01). Quanto à mortalidade, houve 12%, 1,35% e 3,95% de óbitos nos grupos G1, G2 e G3, respectivamente. A mediana do RTS entre os óbitos foi 5,49, 7,84 e 1,16, respectivamente, para os três grupos. a maioria dos pacientes eram homens jovens. O RTS mostrou-se efetivo na predição de mortalidade no trauma cranioencefálico, entretanto falhou ao analisar pacientes vítimas de trauma contuso e penetrante.

Trauma Imaging: A Literature Review.

PubMed

Vela, Jason Heath; Wertz, Christopher Ira; Onstott, Kimberly L; Wertz, Joss R

2017-01-01

To inform radiologic technologists about which imaging modalities and examinations are best suited for evaluating specific anatomical structures in patients who have sustained a traumatic injury. Two scholarly research databases were searched to identify articles focused on trauma imaging of the head, cervical spine, thorax, abdomen, and pelvis. Articles focused on trauma diagnosis were excluded. Thirty-two articles were selected for analysis. Physical examination and plain-film radiographs typically are used to assess nasal bone fracures. Computed tomography (CT) can be used to assess zygomaticomaxillary complex, mandibular, and temporal bone fractures. Traumatic brain injuries are difficult to assess, and broad classifications are used. Depending on the severity of cervical spine trauma, plain-film radiographs or CT imaging is adequate, with magnetic resonance imaging used as a means for further evaluation. Trauma to the thorax typically is assessed with radiography and CT, and CT is recommended for assesment of abdominal and pelvic trauma. The literature was consistent regarding which examinations to perform to best evaluate suspected injuries to the chest, abdomen, and pelvis. The need for, and correct use of, imaging in evaluating trauma to the head and cervical spine is more controversial. Despite the need for additional research, emergency department care providers should be familiar with the structures most commonly injured during trauma and the role of medical imaging for diagnosis.

Trauma-induced pemphigus: a case series of 36 patients.

PubMed

Daneshpazhooh, Maryam; Fatehnejad, Mina; Rahbar, Ziba; Balighi, Kamran; Ghandi, Narges; Ghiasi, Maryam; Abedini, Robabeh; Lajevardi, Vahideh; Chams-Davatchi, Cheyda

2016-02-01

Pemphigus is a group of autoimmune diseases characterized by intraepidermal acantholytic blisters. Isomorphic responses, or Koebner phenomenon (KP), defined as the appearance of typical lesions of a disease following trauma are rarely reported in pemphigus. Our aim was to present patients who developed new pemphigus lesions as a result of skin trauma. The medical files of pemphigus patients from the Autoimmune Bullous Diseases Research Center, who had a history of trauma before the onset or flare of their disease, between 1999 and 2013 were reviewed. Thirty-six pemphigus vulgaris (PV) patients had a history of trauma. Thirteen patients developed new-onset PV and the other 23 had previously been diagnosed with PV. Pemphigus lesions developed most often following major surgeries including abdominal, orthopedic, and chest surgeries as well as dental procedures, blunt physical trauma, and skin surgeries. Moreover, post-cataract laser surgery, burns, radiation therapy, and physiotherapy were also shown to induce pemphigus. Mean time between trauma and lesions was 4.7 weeks for recurrent PV and 15.0 weeks for new-onset PV. Unnecessary surgery and blunt trauma should be avoided in pemphigus patients. Furthermore, posttraumatic pemphigus should be suspected in poorly healing surgical wounds and confirmatory biopsies are mandatory. © 2016 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.

Parents' experiences of their child's admission to paediatric intensive care.

PubMed

Oxley, Ruth

2015-05-01

Admission of a child to the paediatric intensive care unit (PICU) may be one of the most stressful events for parents because the outcome is often uncertain. So how do parents cope, and how can we as nurses help them? To explore the lived experiences of parents whose children have been admitted to a PICU. Using Heidegger's school of interpretative phenomenology, six unstructured interviews were conducted. These were transcribed and analysed following interpretative phenomenological analysis. Participants were chosen through purposive sampling. Each participant had different emergent themes. Themes included trauma, responsibility, anxiety about where the child is, post-traumatic stress symptoms and transfer to the ward. The lived experience of a parent is fraught with varying different emotions, with the beginning of the journey and the ending of the PICU admission causing the most anxiety.

Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia.

PubMed Central

Bickler, S. W.; Sanno-Duanda, B.

2000-01-01

INTRODUCTION: There is a paucity of published data on the type of conditions that require surgery among children in sub-Saharan Africa. Such information is necessary for assessing the impact of such conditions on child health and for setting priorities to improve paediatric surgical care. METHODS: Described in the article is a 29-month prospective study of all children aged < 15 years who were admitted to a government referral hospital in the Gambia from January 1996 to May 1998. RESULTS: A total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of paediatric admissions and 34,625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns. DISCUSSION: Prevention of childhood injuries and better trauma management, especially at the primary and secondary health care levels, should be the priorities for improving paediatric surgical care in sub-Saharan Africa. Surgical care of children should be considered an essential component of child health programmes in developing countries. PMID:11143193

Some observations relating to behind-body armour blunt trauma effects caused by ballistic impact.

PubMed

Lidén, E; Berlin, R; Janzon, B; Schantz, B; Seeman, T

1988-01-01

Live, anesthetised pigs were used to assess behind-armour blunt trauma effects. The thoraco-abdominal body region was covered with varying thicknesses of Kevlar fabric packets. This soft body armour was applied, either in direct contact with the thoracic wall of the animals, or with different plastic foam sheets, so-called trauma packs, between the armour and the skin. The live animals were surgically evaluated, and then sacrificed. Blocks of soft soap were subjected to equal tests and the behind-armour indentations were measured. The results indicate that serious injury to the body armour-protected chest may be caused by the impact of nonpenetrating bullets and shotgun pellets. Severe pulmonary contusions and lacerations were found when the energy transferred through the body armour was estimated to be high.

Penetrating chest trauma caused by a blank cartridge actuated rubber ball projectile: case presentation and ballistic investigation of an uncommon weapon type.

PubMed

Frank, Matthias; Peters, Dieter; Klemm, Wolfram; Grossjohann, Rico; Ekkernkamp, Axel; Bockholdt, Britta; Seifert, Julia

2017-09-01

Recently, an increasing number of an uncommon weapon type based on a caliber 6-mm Flobert blank cartridge actuated revolver which discharges 10-mm-diameter rubber ball projectiles has been confiscated by police authorities following criminal offenses. A recent trauma case presenting with a penetrating chest injury occasioned an investigation into the basic ballistic parameters of this type of weapon. Kinetic energy E of the test projectiles was calculated between 5.8 and 12.5 J. Energy density ED of the test projectiles was close to or higher than the threshold energy density of human skin. It can be concluded that penetrating skin injuries due to free-flying rubber ball projectiles discharged at close range cannot be ruled out. However, in case of a contact shot, the main injury potential of this weapon type must be attributed to the high energy density of the muzzle gas jet which may, similar to well-known gas or alarm weapons, cause life-threatening or even lethal injuries.

Traumatic asphyxia.

PubMed

Montes-Tapia, Fernando; Barreto-Arroyo, Itzel; Cura-Esquivel, Idalia; Rodríguez-Taméz, Antonio; de la O-Cavazos, Manuel

2014-02-01

Traumatic asphyxia is a rare condition in children that usually occurs after severe compression to the chest or abdomen. We report 3 cases in patients 18, 20, and 36 months of age who presented signs and symptoms of traumatic asphyxia after car accidents. Two clinical features were consistent in all 3 patients: multiple petechiae on the face and bulbar conjunctival hemorrhage; 2 patients had facial cyanosis, and 1 had facial edema.In children, the number of clinical manifestations that should be evident to diagnose traumatic asphyxia has not been ascertained. However, in any history of trauma with compression of the chest or abdomen and signs of increased intravenous craniocervical pressure, traumatic asphyxia should be suspected.

PAEDIATRIC CT EXPOSURE PRACTICE IN THE COUNTY OF RIO DE JANEIRO: THE NEED TO ESTABLISH DIAGNOSTIC REFERENCE LEVELS.

PubMed

de Jesus, Fillipe M; Magalhães, Luis A G; Kodlulovich, Simone

2016-11-01

A pilot study of dose indicators in paediatric computed tomography (CT) was conducted to prove the need to establish diagnostic reference levels (DRLs) for the county of Rio de Janeiro. The dose descriptors were estimated from the beam dosimetry by applying the protocols used in each examination. The total patient sample included 279 children. Regarding the comparison of the dose-length product values among the hospitals, the high-resolution chest CT scans were distinguished among the three types of examinations, due to the discrepancies of 1148 % (1-5 y age group) and 2248 % (5-10 y age group) presented in Hospital A's dose-length product values relative to Hospital D's dose-length product values. The results showed that without DRL, the dose variation can be significant between hospitals in the same county for the same age group in the same examination. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Evaluation of the systemic antiinflammatory effects of levosimendan in an experimental blunt thoracic trauma model.

PubMed

Ateş, Gökay; Yaman, Ferda; Bakar, Bülent; Kısa, Üçler; Atasoy, Pınar; Büyükkoçak, Ünase

2017-09-01

Blunt thoracic injury often leads to pulmonary contusion and the development of acute respiratory distress syndrome, which carries a high risk of morbidity and mortality, originating from the local and systemic inflammatory states. This study aimed to investigate the local and systemic antiinflammatory effects of levosimendan in rat models of blunt chest trauma. A total of 32 Wistar albino rats were randomly assigned to one of the following four groups: control, sham, low-dose levosimendan (LDL) (5 µg/kg loading dose for 10 min and 0.05 µg/kg/min intravenous infusion), and high-dose levosimendan (HDL) (10 µg/kg loading dose for 10 min and 0.1 µg/kg/min intravenous infusion). Blunt chest trauma was induced, and after 6 h, the contused pulmonary tissues were histopathologically and immunohistopathologically evaluated, serum TNF-α, IL-1ß, IL-6, and NO levels were biochemically evaluated. The mean arterial pressure was low throughout the experiment in the LDL and HDL groups, with no statistically difference between the groups. Levosimendan reduced the alveolar congestion and hemorrhage, which developed after inducing trauma. Neutrophil infiltration to the damaged pulmonary tissue was also reduced in both the LDL and HDL groups. In rats in which pulmonary contusion (PC) was observed, increased activation of nuclear factor kappa B was observed in the pulmonary tissue, and levosimendan did not reduce this activation. Both high and low doses of levosimendan reduced serum IL-1ß levels, and high doses of levosimendan reduced IL-6 and NO levels. TNF-α levels were not reduced. In conclusion, the results showed that in a rat model of PC, the experimental agent levosimendan could reduce neutrophil cell infiltration to damaged pulmonary tissues and the systemic expressions of some cytokines (IL-1ß, IL-6, and NO), thereby partially reducing and/or correcting pulmonary damage. Systemic inflammatory response that occurs after trauma could also be reduced.

Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients.

PubMed

Akoglu, Haldun; Akoglu, Ebru Unal; Evman, Serdar; Akoglu, Tayfun; Altinok, Arzu Denizbasi; Guneysel, Ozlem; Onur, Ozge Ecmel; Eroglu, Serkan Emre

2013-09-01

The primary goal of this study was to compare the chest wall thicknesses (CWT) at the 2nd intercostal space (ICS) at the mid-clavicular line (MCL) and 5th ICS at the mid-axillary line (MAL) in a population of patients with a CT confirmed pneumothorax (PTX). This result will help physicians to determine the optimum needle thoracostomy (NT) puncture site in patients with a PTX. All trauma patients who presented consecutively to A&E over a 12-month period were included. Among all the trauma patients with a chest CT (4204 patients), 160 were included in the final analysis. CWTs were measured at both sides and were compared in all subgroup of patients. The average CWT for men on the 2nd ICS-MCL was 38mm and for women was 52mm; on the other hand, on the 5th ICS-MAL was 33mm for men and 38mm for women. On the 2nd ICS-MCL 17% of men and 48% of women; on the 5th ICS-MAL 13% of men and 33% of women would be inaccessible with a routine 5-cm catheter. Patients with trauma, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 2nd ICS-MCL. Patients with trauma, lung contusion, sternum fracture, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 5th ICS-MAL. This study confirms that a 5.0-cm catheter would be unlikely to access the pleural space in at least 1/3 of female and 1/10 of male Turkish trauma patients, regardless of the puncture site. If NT is needed, the 5th ICS-MAL is a better option for a puncture site with thinner CWT. Copyright © 2012 Elsevier Ltd. All rights reserved.

Chest x-ray as a screening tool for blunt thoracic trauma in children.

PubMed

Yanchar, Natalie L; Woo, Kenneth; Brennan, Maureen; Palmer, Cameron S; Zs Ee, Michael; Sweeney, Brian; Crameri, Joe

2013-10-01

With the increasing use of thoracic computed tomography (CT) to screen for injuries in pediatric blunt thoracic trauma (BTT), we determined whether chest x-ray (CXR) and other clinical and epidemiologic variables could be used to predict significant thoracic injuries, to inform the selective use of CT in pediatric BTT. We further queried if these were discrepant from factors associated with the decision to obtain a thoracic CT. This retrospective cohort study included cases of BTT from three Level I pediatric trauma centers between April 1999 and March 2008. Pre-CT epidemiologic, clinical, and radiologic variables associated with CT findings of any thoracic injury or a significant thoracic injury as well as the decision to obtain a thoracic CT were determined using logistic regression. Of 425 patients, 40% patients had a significant thoracic injury, 49% had nonsignificant thoracic injury, and 11% had no thoracic injury at all. Presence of hydrothorax and/or pneumothorax on CXR significantly increased the likelihood of significant chest injury visualized by CT (adjusted odds ratio 10.8; 95% confidence interval, 6.5-18), as did the presence of isolated subcutaneous emphysema (adjusted odds ratio, 19.8; 95% confidence interval, 2.3-168). Although a normal CXR finding was not statistically associated with a reduced risk of significant thoracic injury, 8 of the 9 cases with normal CXR findings and significant injuries involved occult pneumothoraces or hemothoraces not requiring intervention. Converse to features suggesting increased risk of significant injury, the decision to obtain a thoracic CT was only associated with later period in the study and obtaining a CT scan of another body region. CXR can be used to screen for significant thoracic injuries and direct the selective use of thoracic CT in pediatric BTT. Prospective studies are needed to validate these findings and develop guidelines that include CXR to define indications for thoracic CT in pediatric BTT. Prognostic study, level III.

Automatic radiation dose monitoring for CT of trauma patients with different protocols: feasibility and accuracy.

PubMed

Higashigaito, K; Becker, A S; Sprengel, K; Simmen, H-P; Wanner, G; Alkadhi, H

2016-09-01

To demonstrate the feasibility and accuracy of automatic radiation dose monitoring software for computed tomography (CT) of trauma patients in a clinical setting over time, and to evaluate the potential of radiation dose reduction using iterative reconstruction (IR). In a time period of 18 months, data from 378 consecutive thoraco-abdominal CT examinations of trauma patients were extracted using automatic radiation dose monitoring software, and patients were split into three cohorts: cohort 1, 64-section CT with filtered back projection, 200 mAs tube current-time product; cohort 2, 128-section CT with IR and identical imaging protocol; cohort 3, 128-section CT with IR, 150 mAs tube current-time product. Radiation dose parameters from the software were compared with the individual patient protocols. Image noise was measured and image quality was semi-quantitatively determined. Automatic extraction of radiation dose metrics was feasible and accurate in all (100%) patients. All CT examinations were of diagnostic quality. There were no differences between cohorts 1 and 2 regarding volume CT dose index (CTDIvol; p=0.62), dose-length product (DLP), and effective dose (ED, both p=0.95), while noise was significantly lower (chest and abdomen, both -38%, p<0.017). Compared to cohort 1, CTDIvol, DLP, and ED in cohort 3 were significantly lower (all -25%, p<0.017), similar to the noise in the chest (-32%) and abdomen (-27%, both p<0.017). Compared to cohort 2, CTDIvol (-28%), DLP, and ED (both -26%) in cohort 3 was significantly lower (all, p<0.017), while noise in the chest (+9%) and abdomen (+18%) was significantly higher (all, p<0.017). Automatic radiation dose monitoring software is feasible and accurate, and can be implemented in a clinical setting for evaluating the effects of lowering radiation doses of CT protocols over time. Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Randomised clinical trial of chest drainage systems.

PubMed Central

Graham, A N; Cosgrove, A P; Gibbons, J R; McGuigan, J A

1992-01-01

BACKGROUND: Problems in the management of thoracic trauma have stimulated the search for an alternative to underwater seals for drainage of the pleural cavity. A chest drainage bag incorporating a one way flutter valve has been compared with underwater seal drains in a randomised clinical trial. METHODS: During June-December 1989 119 patients undergoing elective thoracotomy were randomised to receive postoperative chest drainage by drainage bags (56 patients, 87 drains) or by underwater seal drains (63 patients, 98 drains). Daily drainage volumes, the requirement for pleural suction, mobility, and complications were recorded prospectively. RESULTS: There was no significant difference between the two groups in the mean volume drained, the requirements for pleural suction, or the occurrence of complications. Patients with drainage bags were fully mobile 23 hours (95% confidence interval 0-47 hours) earlier than the others. CONCLUSIONS: When used after elective thoracotomy drainage bags are safe and effective and permit earlier mobility than underwater seal drains. PMID:1496507

Role of Complement C5 in Experimental Blunt Chest Trauma-Induced Septic Acute Lung Injury (ALI)

PubMed Central

Karbach, Michael; Braumueller, Sonja; Kellermann, Philipp; Gebhard, Florian; Huber-Lang, Markus; Perl, Mario

2016-01-01

Background Severe blunt chest trauma is associated with high mortality. Sepsis represents a serious risk factor for mortality in acute respiratory distress syndrome (ARDS). In septic patients with ARDS complement activation products were found to be elevated in the plasma. In single models like LPS or trauma complement has been studied to some degree, however in clinically highly relevant double hit models such as the one used here little data is available. Here, we hypothesized that absence of C5 is correlated with a decreased inflammatory response in trauma induced septic acute lung injury. Methods 12 hrs after DH in mice the local and systemic cytokines and chemokines were quantified by multiplex bead array or ELISA, activated caspase-3 by western blot. Data were analyzed using one-way ANOVA followed by post-hoc Sidak’s multiple comparison test (significance, p≤ 0.05). Results In lung tissue interleukin (IL)-6, monocyte chemo attractant protein-1 (MCP-1) and granulocyte-colony stimulating factor (G-CSF) was elevated in both C5-/- mice and wildtype littermates (wt), whereas caspase-3 was reduced in lungs after DH in C5-/- mice. Systemically, reduced keratinocyte-derived chemokine (KC) levels were observed after DH in C5-/- compared to wt mice. Locally, lung myeloperoxidase (MPO), protein, IL-6, MCP-1 and G-CSF in brochoalveolar lavage fluid (BALF) were elevated after DH in C5-/- compared to wt. Conclusions In the complex but clinically relevant DH model the local and systemic inflammatory immune response features both, C5-dependent and C5-independent characteristics. Activation of caspase-3 in lung tissue after DH was C5-dependent whereas local inflammation in lung tissue was C5-independent. PMID:27437704

Predictors of abdominal injuries in blunt trauma.

PubMed

Farrath, Samiris; Parreira, José Gustavo; Perlingeiro, Jacqueline A G; Solda, Silvia C; Assef, José Cesar

2012-01-01

To identify predictors of abdominal injuries in victims of blunt trauma. retrospective analysis of trauma protocols (collected prospectively) of adult victims of blunt trauma in a period of 15 months. Variables were compared between patients with abdominal injuries (AIS>0) detected by computed tomography or/and laparotomy (group I) and others (AIS=0, group II). Student's t, Fisher and qui-square tests were used for statistical analysis, considering p<0.05 as significant. A total of 3783 cases were included, with a mean age of 39.1 ± 17.7 years (14-99), 76.1% being male. Abdominal injuries were detected in 130 patients (3.4%). Patients sustaining abdominal injuries had significantly lower mean age (35.4 + 15.4 vs. 39.2 + 17.7), lower mean systolic blood pressure on admission (114.7 + 32.4 mmHg vs. 129.1 + 21.7 mmHg), lower mean Glasgow coma scale (12.9 + 3.9 vs. 14.3 + 2.0), as well as higher head AIS (0.95 + 1.5 vs. 0.67 + 1.1), higher thorax AIS (1.10 + 1.5 vs. 0.11 + 0.6) and higher extremities AIS (1.70 ± 1.8 vs. 1.03 ± 1.2). Patients sustaining abdominal injuries also presented higher frequency of severe injuries (AIS>3) in head (18.5% vs. 7.9%), thorax (29.2% vs. 2.4%) and extremities (40.0% vs. 13.7%). The highest odds ratios for the diagnosis of abdominal injuries were associated flail chest (21.8) and pelvic fractures (21.0). Abdominal injuries were more frequently observed in patients with hemodynamic instability, changes in Glasgow coma scale and severe lesions to the head, chest and extremities.

Role of Complement C5 in Experimental Blunt Chest Trauma-Induced Septic Acute Lung Injury (ALI).

PubMed

Kalbitz, Miriam; Karbach, Michael; Braumueller, Sonja; Kellermann, Philipp; Gebhard, Florian; Huber-Lang, Markus; Perl, Mario

2016-01-01

Severe blunt chest trauma is associated with high mortality. Sepsis represents a serious risk factor for mortality in acute respiratory distress syndrome (ARDS). In septic patients with ARDS complement activation products were found to be elevated in the plasma. In single models like LPS or trauma complement has been studied to some degree, however in clinically highly relevant double hit models such as the one used here little data is available. Here, we hypothesized that absence of C5 is correlated with a decreased inflammatory response in trauma induced septic acute lung injury. 12 hrs after DH in mice the local and systemic cytokines and chemokines were quantified by multiplex bead array or ELISA, activated caspase-3 by western blot. Data were analyzed using one-way ANOVA followed by post-hoc Sidak's multiple comparison test (significance, p≤ 0.05). In lung tissue interleukin (IL)-6, monocyte chemo attractant protein-1 (MCP-1) and granulocyte-colony stimulating factor (G-CSF) was elevated in both C5-/- mice and wildtype littermates (wt), whereas caspase-3 was reduced in lungs after DH in C5-/- mice. Systemically, reduced keratinocyte-derived chemokine (KC) levels were observed after DH in C5-/- compared to wt mice. Locally, lung myeloperoxidase (MPO), protein, IL-6, MCP-1 and G-CSF in brochoalveolar lavage fluid (BALF) were elevated after DH in C5-/- compared to wt. In the complex but clinically relevant DH model the local and systemic inflammatory immune response features both, C5-dependent and C5-independent characteristics. Activation of caspase-3 in lung tissue after DH was C5-dependent whereas local inflammation in lung tissue was C5-independent.

Radiation dose optimisation for conventional imaging in infants and newborns using automatic dose management software: an application of the new 2013/59 EURATOM directive.

PubMed

Alejo, L; Corredoira, E; Sánchez-Muñoz, F; Huerga, C; Aza, Z; Plaza-Núñez, R; Serrada, A; Bret-Zurita, M; Parrón, M; Prieto-Areyano, C; Garzón-Moll, G; Madero, R; Guibelalde, E

2018-04-09

Objective: The new 2013/59 EURATOM Directive (ED) demands dosimetric optimisation procedures without undue delay. The aim of this study was to optimise paediatric conventional radiology examinations applying the ED without compromising the clinical diagnosis. Automatic dose management software (ADMS) was used to analyse 2678 studies of children from birth to 5 years of age, obtaining local diagnostic reference levels (DRLs) in terms of entrance surface air kerma. Given local DRL for infants and chest examinations exceeded the European Commission (EC) DRL, an optimisation was performed decreasing the kVp and applying the automatic control exposure. To assess the image quality, an analysis of high-contrast resolution (HCSR), signal-to-noise ratio (SNR) and figure of merit (FOM) was performed, as well as a blind test based on the generalised estimating equations method. For newborns and chest examinations, the local DRL exceeded the EC DRL by 113%. After the optimisation, a reduction of 54% was obtained. No significant differences were found in the image quality blind test. A decrease in SNR (-37%) and HCSR (-68%), and an increase in FOM (42%), was observed. ADMS allows the fast calculation of local DRLs and the performance of optimisation procedures in babies without delay. However, physical and clinical analyses of image quality remain to be needed to ensure the diagnostic integrity after the optimisation process. Advances in knowledge: ADMS are useful to detect radiation protection problems and to perform optimisation procedures in paediatric conventional imaging without undue delay, as ED requires.

Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects.

PubMed

Thiam, Ousmane; Konate, Ibrahima; Gueye, Mohamadou Lamine; Toure, Alpha Omar; Seck, Mamadou; Cisse, Mamadou; Diop, Balla; Dirie, Elias Said; Ka, Ousmane; Thiam, Mbaye; Dieng, Madieng; Dia, Abdarahmane; Toure, Cheikh Tidiane

2016-01-01

Diaphragmatic injuries include wounds and diaphragm ruptures, due to a thoracoabdominal blunt or penetrating traumas. Their incidence ranges between 0.8 and 15 %. The diagnosis is often delayed, despite several medical imaging techniques. The surgical management remains controversal, particularly for the choice of the surgical approach and technique. The mortality is mainly related to associated injuries. The aim of our study was to evaluate the incidence of diaphragmatic injuries occuring in thoraco-abdominal traumas, and to discuss their epidemiology, diagnosis and treatment. We performed a retrospective study over a period of 21 years, between January 1994 and June 2015 at the Department of General Surgery of the Aristide Le Dantec hospital in Dakar, Senegal. All patients diagnosed with diaphragmatic injuries were included in the study. Over the study period, 1535 patients had a thoraco-abdominal trauma. There were 859 cases of blunt trauma, and 676 penetrating chest or abdominal trauma. Our study involved 20 cases of diaphragmatic injuries (1.3 %). The sex-ratio was 4. The mean age was 33 years. Brawls represented 83.3 % (17 cases). Stab attacks represented 60 % (12 cases). The incidence of diaphragmatic injury was 2.6 %. The wound was in the thorax in 60 % (seven cases). Chest radiography was contributory in 45 % (nine cases). The diagnosis of wounds or ruptures of the diaphragm was done preoperatively in 45 % (nine cases). The diaphragmatic wound was on the left side in 90 % (18 cases) and its mean size was 4.3 cm. The surgical procedure involved a reduction of herniated viscera and a suture of the diaphragm by "X" non absorbable points in 85 % (17 cases). A thoracic aspiration was performed in all patients. Morbidity rate was 10 % and mortality rate 5 %. The diagnosis of diaphragmatic rupture and wounds remains difficult and often delayed. They should be kept in mind in any blunt or penetrating thoraco-abdominal trauma. Diaphragmatic lesions are usually located on the left side. Surgery is an efficient treatment.

The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury?

PubMed

Brown, Joshua B; Gestring, Mark L; Leeper, Christine M; Sperry, Jason L; Peitzman, Andrew B; Billiar, Timothy R; Gaines, Barbara A

2017-06-01

The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS greater than 15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and Abbreviated Injury Scale (AIS) to predict mortality and define optimal thresholds of severe injury in pediatric trauma. Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as younger than 16 years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cutoff for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated the association between mortality and maximum AIS in each body region, controlling for age, mechanism, and nonaccidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed. Included were 352,127 adults and 50,579 children. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cutoff in children was ISS greater than 25 and had a positive predictive value of 19% and negative predictive value of 99% compared to a positive predictive value of 7% and negative predictive value of 99% for ISS greater than 15 to predict mortality. In single-system-injured children, mortality was associated with head (odds ratio, 4.80; 95% confidence interval, 2.61-8.84; p < 0.01) and chest AIS (odds ratio, 3.55; 95% confidence interval, 1.81-6.97; p < 0.01), but not abdomen, face, neck, spine, or extremity AIS (p > 0.05). For multisystem injury, all body region AIS scores were associated with mortality except extremities. Sensitivity analysis demonstrated ISS greater than 23 to predict need for full trauma activation, and ISS greater than 26 to predict impaired functional independence were optimal thresholds. An ISS greater than 25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system-injured children. These findings should be considered in benchmarking and performance improvement efforts. Epidemiologic study, level III.

Function of "nontrauma" surgeons in level I trauma centers in the United States.

PubMed

Pate, J W

1997-06-01

Although the general "trauma" surgeon is usually the team leader in level I trauma centers, the use of surgical subspecialists and nonsurgeons is frequently ill-defined. This study was done to gain data in regard to actual use of subspecialists in busy centers. First, a survey of the patterns of staffing in 140 trauma centers was elicited by mail questionnaire, supplemented by telephone cells. Second, records of 400 consecutive patients at the Elvis Presley Trauma Center were reviewed to determine the use of subspecialists during the first 24 hours of care of individual patients. There were differences in the use of surgical subspecialists and nonsurgeons at different centers: in receiving, admitting, operating, and critical care areas and in privileges for admission and attending of inpatients. Consultation "guidelines" are used for many specific injuries. At our center, a mean of 1.92 subspecialists, in addition to general surgeons, were involved in the early care of each patient. Problems exist in many centers regarding the use of subspecialists, especially for management of facial and chest injuries. In some centers nonsurgeons function in the intensive care unit, and as admitting and attending physicians of trauma patients.

Is there a need for a clinical decision rule in blunt wrist trauma?

PubMed

van den Brand, Crispijn L; van Leerdam, Roderick H; van Ufford, Jet H M E Quarles; Rhemrev, Steven J

2013-11-01

Blunt wrist trauma is a very common injury in emergency medicine. However, in contrast to other extremity trauma, there is no clinical decision rule for radiography in patients with blunt wrist trauma. The purpose of this study is to describe current practice and to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma. All patients with blunt wrist trauma who presented to our Emergency Department (ED) during a 6-month period were included in this study. Basic demographics were analysed and the radiography ratio was determined. The radiography results were compared for different demographic groups. Current practice and the need and feasibility for a decision rule were evaluated using Stiell's checklist for clinical decision rules. A total of 1019 patients with 1032 blunt wrist injuries presented at our ED in a period of 6 months. In 91.4% of patients, radiographs were taken. In 41.6% of those radiographed, a fracture was visible on plain radiography. Fractures were most common in the paediatric and senior age groups. However, even in the lower-risk groups we observed a fracture incidence of about 20%. There is no need for a clinical decision rule for radiography in patients with blunt wrist trauma because the fracture ratio is high. Neither does it seem feasible to develop a highly sensitive and efficient decision rule. Therefore, the authors recommend radiography in all patients with blunt wrist trauma presenting to the ED. Copyright © 2013 Elsevier Ltd. All rights reserved.

Population-based study of ischemic stroke risk after trauma in children and young adults.

PubMed

Fox, Christine K; Hills, Nancy K; Vinson, David R; Numis, Adam L; Dicker, Rochelle A; Sidney, Stephen; Fullerton, Heather J

2017-12-05

To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected. © 2017 American Academy of Neurology.

Validation of ICDPIC software injury severity scores using a large regional trauma registry.

PubMed

Greene, Nathaniel H; Kernic, Mary A; Vavilala, Monica S; Rivara, Frederick P

2015-10-01

Administrative or quality improvement registries may or may not contain the elements needed for investigations by trauma researchers. International Classification of Diseases Program for Injury Categorisation (ICDPIC), a statistical program available through Stata, is a powerful tool that can extract injury severity scores from ICD-9-CM codes. We conducted a validation study for use of the ICDPIC in trauma research. We conducted a retrospective cohort validation study of 40,418 patients with injury using a large regional trauma registry. ICDPIC-generated AIS scores for each body region were compared with trauma registry AIS scores (gold standard) in adult and paediatric populations. A separate analysis was conducted among patients with traumatic brain injury (TBI) comparing the ICDPIC tool with ICD-9-CM embedded severity codes. Performance in characterising overall injury severity, by the ISS, was also assessed. The ICDPIC tool generated substantial correlations in thoracic and abdominal trauma (weighted κ 0.87-0.92), and in head and neck trauma (weighted κ 0.76-0.83). The ICDPIC tool captured TBI severity better than ICD-9-CM code embedded severity and offered the advantage of generating a severity value for every patient (rather than having missing data). Its ability to produce an accurate severity score was consistent within each body region as well as overall. The ICDPIC tool performs well in classifying injury severity and is superior to ICD-9-CM embedded severity for TBI. Use of ICDPIC demonstrates substantial efficiency and may be a preferred tool in determining injury severity for large trauma datasets, provided researchers understand its limitations and take caution when examining smaller trauma datasets. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Mitral and tricuspid valve rupture after moderate blunt chest trauma.

PubMed

Bailey, P L; Peragallo, R; Karwande, S V; Lapunzina, P

2000-02-01

We present a patient with rupture of both atrioventricular valves in a previously healthy adult man who sustained a 5-foot fall. The mechanism of injury was such that it would not necessarily raise an adequate index of suspicion for valvular damage had valvular rupture not occurred. The usefulness of perioperative echocardiography is highlighted.

Application of laser-video thoracoscopic surgery

NASA Astrophysics Data System (ADS)

Gu, Xu-Dong; Zhu, Jing; Zhu, Hong-Sheng

1998-11-01

10 patients were treated by video-assisted-thoracoscopic surgery with laser in this article. No patient has complications of intrathoracic infection and air leakage of lung or died from the operation. Without opening the chest, it has less trauma as well as a better homeostatic effect. It is available for the patients who are old or have poor cardio-pulmonary function.

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study.

PubMed

Bradley, Matthew; Okoye, Obi; DuBose, Joseph; Inaba, Kenji; Demetriades, Demetrios; Scalea, Thomas; O'Connor, James; Menaker, Jay; Morales, Carlos; Shiflett, Tony; Brown, Carlos

2013-09-01

Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH. We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived. 328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH. To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors. Published by Elsevier Ltd.

Clinical features and management of facial nerve paralysis in children: analysis of 24 cases.

PubMed

Cha, H E; Baek, M K; Yoon, J H; Yoon, B K; Kim, M J; Lee, J H

2010-04-01

To evaluate the causes, treatment modalities and recovery rate of paediatric facial nerve paralysis. We analysed 24 cases of paediatric facial nerve paralysis diagnosed in the otolaryngology department of Gachon University Gil Medical Center between January 2001 and June 2006. The most common cause was idiopathic palsy (16 cases, 66.7 per cent). The most common degree of facial nerve paralysis on first presentation was House-Brackmann grade IV (15 of 24 cases). All cases were treated with steroids. One of the 24 cases was also treated surgically with facial nerve decompression. Twenty-two cases (91.6 per cent) recovered to House-Brackmann grade I or II over the six-month follow-up period. Facial nerve paralysis in children can generally be successfully treated with conservative measures. However, in cases associated with trauma, radiological investigation is required for further evaluation and treatment.

Burnout and posttraumatic stress in paediatric critical care personnel: Prediction from resilience and coping styles.

PubMed

Rodríguez-Rey, Rocío; Palacios, Alba; Alonso-Tapia, Jesús; Pérez, Elena; Álvarez, Elena; Coca, Ana; Mencía, Santiago; Marcos, Ana; Mayordomo-Colunga, Juan; Fernández, Francisco; Gómez, Fernando; Cruz, Jaime; Ordóñez, Olga; Llorente, Ana

2018-03-28

Our aims were (1) to explore the prevalence of burnout syndrome (BOS) and posttraumatic stress disorder (PTSD) in a sample of Spanish staff working in the paediatric intensive care unit (PICU) and compare these rates with a sample of general paediatric staff and (2) to explore how resilience, coping strategies, and professional and demographic variables influence BOS and PTSD. This is a multicentre, cross-sectional study. Data were collected in the PICU and in other paediatric wards of nine hospitals. Participants consisted of 298 PICU staff members (57 physicians, 177 nurses, and 64 nursing assistants) and 189 professionals working in non-critical paediatric units (53 physicians, 104 nurses, and 32 nursing assistants). They completed the Brief Resilience Scale, the Coping Strategies Questionnaire for healthcare providers, the Maslach Burnout Inventory, and the Trauma Screening Questionnaire. Fifty-six percent of PICU working staff reported burnout in at least one dimension (36.20% scored over the cut-off for emotional exhaustion, 27.20% for depersonalisation, and 20.10% for low personal accomplishment), and 20.1% reported PTSD. There were no differences in burnout and PTSD scores between PICU and non-PICU staff members, either among physicians, nurses, or nursing assistants. Higher burnout and PTSD rates emerged after the death of a child and/or conflicts with patients/families or colleagues. Around 30% of the variance in BOS and PTSD is predicted by a frequent usage of the emotion-focused coping style and an infrequent usage of the problem-focused coping style. Interventions to prevent and treat distress among paediatric staff members are needed and should be focused on: (i) promoting active emotional processing of traumatic events and encouraging positive thinking; (ii) developing a sense of detached concern; (iii) improving the ability to solve interpersonal conflicts, and (iv) providing adequate training in end-of-life care. Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

[Traumatic tricuspid insufficiency].

PubMed

Vayre, F; Richard, P; Ollivier, J P

1996-04-01

Traumatic tricuspid insufficiency is a rare condition. The diagnosis is difficult because of the slow progression of this pathology and the presence of more clinically acute lesions. Non-penetrating chest trauma is responsible for 90% of cases. Echocardiography is the investigation of choice for assessing the mechanism of the tricuspid regurgitation and for diagnosing associated lesions. It should be performed systematically in patients with multiple trauma. The surgical indications are difficult to determine and depend on the patients' symptoms and the type of anatomical lesions. It should be undertaken before right ventricular myocardial dysfunction. Several techniques may be used from valvuloplasty to valve replacement mainly with bioprostheses in symptomatic patients.

[Chronic chest pain after rib fracture: It can cause a disability?

PubMed

Rabiou, S; Ouadnouni, Y; Lakranbi, M; Traibi, A; Antoini, F; Smahi, M

2018-04-01

The rib fractures and instability of the chest wall are the main lesions of closed chest trauma. These lesions can be a source of chronic, often disabling with daily discomfort resulting limitation of some activities. The objective of this study was to assess the prevalence of this phenomenon in order to improve the quality of early care. Through an observational retrospective cohort study on a number of 41 patients supported and monitored for traumatic rib fractures at the Military Hospital of Meknes during the period from October 2010 to March 2016. The circumstances of the accident were dominated by accidents of public roads (86%) and concerned the young adult male. Radiographs have enumerated 165 fracture lines with an average of 4 rib fractures per patient. These were unilateral fractures in 88% of cases, and concerned the means arc in 46% of cases. The rib fracture was undisplaced fracture in 39% of patients, whereas in 2 patients, a flail chest was present. Post-traumatic hemothorax (63% of cases) were the thoracic lesions most commonly associated with rib fractures. The initial management consisted in the use of analgesics systemically in all patients. The retrospective evaluation of pain by the verbal scale was possible in 30 patients. The persistent pain was noted in 60% of cases. This pain was triggered by a simple effort to moderate in 55% of cases, and hard effort in 28% of cases. In 17% of patients, even at rest, the pain occurred intermittently. The impact in terms of disability was mild to moderate in 28% of cases and important in 17%. The neuropathic pain was found in 3 patients. Therapeutically, the first and second levels of analgesics were sufficient to relieve pain. The neuroleptics were required for 2 patients. Our study confirms the persistence of chronic painful, sometimes lasting several years after the initial chest trauma. This pain is responsible of disability triggered most often after exercise. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Paediatric injuries at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 150 cases

PubMed Central

2013-01-01

Background Injuries continue to be the leading cause of death and disability for children. The is a paucity of published data on paediatric injuries in our local environment. This study describes the etiological spectrum, injury characteristics and treatment outcome of paediatric injuries in our local setting and provides baseline data for establishment of prevention strategies as well as treatment guidelines. Methods This was a descriptive cross-sectional study involving paediatric injury patients admitted to Bugando Medical Centre from August 2011 to April 2012. Statistical data analysis was done using SPSS version 17.0 and STATA version 12.0. Results A total of 150 patients were studied. The age of patients ranged from 1 month to 10 years with a median age of 5 years. The male to female ratio was 2.3:1. Road traffic accident was the most common cause of injury (39.3%) and motorcycle (71.2%) was responsible for the majority of road traffic accidents. Only 11 (7.3%) patients received pre-hospital care. The head /neck (32.7%) and musculoskeletal (28.0%) were the most frequent body region injured. Open wounds (51.4%), foreign bodies (31.3%) and fractures (17.3%) were the most common type of injuries sustained. The majority of patients 84 (56.0%) were treated surgically. Complication rate was 3.9%. The mean duration of hospitalization was 9.7 ± 13.1 days. Mortality rate was 12.7%. Age of the patient (< 5 years), late presentation and presence of complications were the main predictors of length of hospital stay (P < 0.001), whereas burn injuries, severe head injuries and severity of injury (Paediatric trauma score = 0–5) significantly predicted mortality (P < 0.0001). Conclusion Paediatric injuries resulting from road traffic accidents (RTAs) remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of paediatric injuries in this region. PMID:24499558

Successful management of threatened aortic rupture late after rib fracture caused by blunt chest trauma.

PubMed

Morimoto, Yoshihisa; Sugimoto, Takaki; Sakahira, Hideki; Matsuoka, Hidehito; Yoshioka, Yuki; Arase, Hiroki

2014-05-01

A 62-year-old man was crushed in a car accident and diagnosed with a fractured left ninth rib, pulmonary and heart contusion, hemopneumothorax, and descending aortic injury based on a computed tomography scan. He underwent chest tube drainage and was intubated for mechanical ventilation because a bone fragment of the ninth rib threatened to penetrate the descending aorta. On the second posttrauma day, computed tomography showed the bone fragment of the ninth rib approaching the descending aorta. He underwent graft replacement of the injured portion of the descending thoracic aorta, and we removed the fractured left ninth rib. Copyright © 2014 Elsevier Inc. All rights reserved.

[Fulminant isolated necrotizing fasciitis of the chest wall, complicating thoracic empyema].

PubMed

Kovács, Ottó; Szántó, Zoltán; Krasznai, Géza

2016-03-01

Authors introduce the case of a 64-year-old male patient with fulminant isolated necrotizing fasciitis of the chest wall, complicating empyema thoracis of unknown origin. The patient's co-morbidities were hypertension, ischaemic heart disease, atrial fibrillation with oral anticoagulation. The real etiology was revealed post mortem, due to the rapid progression. The autopsy demonstrated that the fasciitis was caused by a small blunt thoracic trauma (haematoma), not emerged from patient's history and was not visible during physical examination. Authors review diagnostic pitfalls, leading to delayed recognition in addition to this very case. After quick diagnosis surgical debridement, targeted wide spectrum antibiotics and maximal intensive care are the basic pillars of the management of necrotizing fasciitis.

An epidemiological study of paediatric motocross injuries in the United Kingdom.

PubMed

Singh, Rohit; Malhotra, Akshay; Kyle, Nigel; Hay, Stuart

2015-10-01

Although off-road motorcycling is one of the most popular sports activities practised by millions of people worldwide, little has been written on motocross injuries and their prevention. In the UK alone, motocross has grown into a phenomenally ambitious and popular franchise. There are >200 motocross clubs across the country holding >900 events annually. The aim of this study is to categorise and quantify the magnitude of motocross paediatric injuries and associated morbidity. Data were collected prospectively over 4 years (2010-2014) at our unit. All injuries caused by motocross biking that were referred to our trauma and orthopaedic department were included in this study, regardless of whether the rider was performing the sport competitively or recreationally. During the study period, 130 patients (aged 4-17 years) were identified with a total of 142 injuries, ranging from one to six injuries per patient. Most of the injuries were sustained within the early spring and summer months, representing the start of the motocross season; 76 patients required hospital admission, with 60 (42 %) requiring surgical intervention. We present the first epidemiological study of motocross paediatric injuries in the UK. The results from this study highlight the frequency and severity of motocross-related injuries in the paediatric population in the UK. This may assist in providing recommendations and guidelines to governing bodies and to parents. The injuries sustained during motocross have significant resource implications, especially for smaller rural hospitals, as shown by the number of injuries doubling over the past 4 years.

Radiation dose from common radiological investigations and cumulative exposure in children with cystic fibrosis: an observational study from a single UK centre

PubMed Central

Ward, Rebecca; Carroll, William D; Cunningham, Paula; Ho, Sheng-Ang; Jones, Mary; Lenney, Warren; Thompson, David

2017-01-01

Objectives Cumulative radiation exposure is associated with increased risk of malignancy. This is important in cystic fibrosis (CF) as frequent imaging is required to monitor disease progression and diagnose complications. Previous estimates of cumulative radiation are outdated as the imaging was performed on older equipment likely to deliver higher radiation. Our objectives were to determine the radiation dose delivered to children during common radiological investigations using modern equipment and to identify the number of such investigations performed in a cohort of children with CF to calculate their cumulative radiation exposure. Design, setting and participants Data including age at investigation and radiation exposure measured as estimated effective dose (EED) were collected on 2827 radiological studies performed on children at one UK paediatric centre. These were combined with the details of all radiological investigations performed on 65 children with CF attending the same centre to enable calculation of each child’s cumulative radiation exposure. Results The mean EED for the common radiological investigations varied according to age. The range was 0.01–0.02 mSv for chest X-rays, 0.03–0.11 mSv for abdominal X-rays, 0.57–1.69 mSv for CT chest, 2.9–3.9 mSv for abdominal and pelvic CT, 0.20–0.21 mSv for sinus CT and 0.15–0.52 mSv for fluoroscopy-guided procedures. The mean EED was three to five times higher for helical compared with axial chest CT scans. The mean annual cumulative EED for our cohort of children with CF was 0.15 mSv/year with an estimated cumulative paediatric lifetime EED (0–18 years) of 3.5 mSv. Conclusions This study provides up-to-date estimations of the radiation exposure when using common radiological investigations. These doses and the estimates of cumulative radiation exposure in children with CF are lower than previously reported. This reflects the reduced EED associated with modern equipment and the use of age-specific scanning protocols. PMID:28827272

The full spectrum of handlebar injuries in children: a decade of experience.

PubMed

Nataraja, R M; Palmer, C S; Arul, G S; Bevan, C; Crameri, J

2014-04-01

Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI. Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI. 1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively. Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion. Copyright © 2013. Published by Elsevier Ltd.

Horse-related injuries in children - unmounted injuries are more severe: A retrospective review.

PubMed

Wolyncewicz, Grace E L; Palmer, Cameron S; Jowett, Helen E; Hutson, John M; King, Sebastian K; Teague, Warwick J

2018-05-01

Horse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients. Trauma registry data were reviewed for 505 consecutive paediatric patients (aged<16years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests. More patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0days vs 1.1days; p<0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury. Horse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity. Copyright © 2017 Elsevier Ltd. All rights reserved.

Basic and advanced paediatric cardiopulmonary resuscitation - guidelines of the Australian and New Zealand Resuscitation Councils 2010.

PubMed

Tibballs, James; Aickin, Richard; Nuthall, Gabrielle

2012-07-01

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres. © 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Paediatric primary care in Inner London

PubMed Central

Jackson, Jane

1980-01-01

A week's census was taken of children attending family doctors or hospital accident and emergency departments in an inner city area of London. Most attendances at general hospitals were for cases of trauma while the children's hospital was used mainly by the very young, coming from a wide catchment area. An over-emphasis on hospital-based primary care would not be appropriate in this area and would run counter to the whole philosophy of British medical practice. ImagesFigure 1.Figure 4. PMID:7452588

Trauma Reports. Volume 12, Number 6, November/December 2011

DTIC Science & Technology

2011-12-01

symptoms often receive a chest CT early in the course of resuscitation to determine the severity of disease, but deciding which patients with...not eliminate the risk of having severe pulmonary dysfunction and respiratory compromise. Resuscitation . After arrival to the hospital, the...Fluid Resuscitation . There is per- sistent controversy surrounding the issue of fluid management in patients with pulmonary contusions. The

Valve repair for traumatic tricuspid regurgitation.

PubMed

Maisano, F; Lorusso, R; Sandrelli, L; Torracca, L; Coletti, G; La Canna, G; Alfieri, O

1996-01-01

The review of six cases of valve repair for traumatic tricuspid regurgitation in our institution and 74 in the literature in order to assess effective methods of treating this lesion. Tricuspid valve regurgitation is a rare complication of blunt chest trauma. Optimal treatment for this condition is still controversial ranging from long-term medical therapy to early surgical correction. We followed the cases of six consecutive patients with post-traumatic tricuspid incompetence who were successfully treated with reparative techniques. All patients were male and their ages ranged from 18 years to 42 years. Valve regurgitation was always secondary to blunt chest trauma due to motor vehicle accident. The mechanism of valve insufficiency was invariably anterior leaflet prolapse due to chordal or papillary muscle rupture associated with annular dilatation. Surgical procedures included Carpentier ring implant (5 patients), Bex posterior annuloplasty (1 patient), implant of artificial chordae (4 patients), papillary muscle reinsertion (2 patients), commissuroplasty (1 patient) and "artificial double orifice" technique (1 patient). Tricuspid insufficiency improved in all patients after the correction. No complications were recorded and all patients were asymptomatic at the follow-up. Since post-traumatic tricuspid regurgitation is effectively correctable with reparative techniques, early operation is recommended to relieve symptoms and to prevent right ventricular dysfunction.

Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy.

PubMed

Huang, Wen-Yen; Lu, I-Yin; Yang, Chyan; Chou, Yi-Pin; Lin, Hsing-Lin

2016-01-01

Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%, P = 0.061) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27, P = 0.029) and in the hospital (15.93 versus 23.17, P = 0.01) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS.

Delayed hypersensitivity and neutrophil chemotaxis: effect of trauma.

PubMed

Meakins, J L; McLean, A P; Kelly, R; Bubenik, O; Pietsch, J B; MacLean, L D

1978-04-01

To investigate alterations in host defense produced by trauma, skin testing with five standard recall antigens was done on admission and weekly on 53 patients with blunt trauma and seven with penetrating missile injuries, who then were classified as normal (N), 2 or more positive responses; relatively anergic (RA), one positive response; or anergic (A), no response. Neutrophil chemotaxis was tested 145 times in 32 patients. Degree of injury was assessed by assigning one point to pelvic fracture, long-bone fracture, head, chest, or abdominal injury, to a maximum of five. The A and RA patients had greater trauma, 3 vs. 1.6 for N, and a significantly increased rate of sepsis (p less than 0.005) and mortality (p less than 0.05). Incidence of anergy depended upon age and extent of trauma. Neutrophil chemotaxis in A and RA patients was significantly (p less than 0.001) worse at 96.7 +/- 2.4 mu and 99.8 +/- 1.7 mu compared to N, 113.2 +/- 1.7 mu, and controls 121 +/- 4 mu. With recovery, chemotaxis returned to normal. It is concluded that failure of delayed hypersensitivity responses follows trauma, is related to the severity of injury and age of patient, and is associated with an abnormality of neutrophil chemotaxis and increased rate of sepsis.

Occult pneumothoraces in Chinese patients with significant blunt chest trauma: radiological classification and proposed clinical significance.

PubMed

Lee, Ryan K L; Graham, Colin A; Yeung, Janice H H; Ahuja, Anil T; Rainer, Timothy H

2012-12-01

An occult pneumothorax (OP) is a pneumothorax not seen on a supine chest X-ray (CXR) but detected on abdominal or thoracic computed tomography (CT) scanning. With the increasing use of CT in the management of significantly injured trauma patients, more OPs are being detected. The aim of this study was to classify OPs diagnosed on thoracic CT (TCT) and correlate them with their clinical significance. Retrospective analysis of prospectively collected trauma registry data. Total 36 (N=36) consecutive significantly injured trauma patients admitted through the emergency department (ED) who sustained blunt chest trauma and underwent TCT between 1 January 2007 and 31 December 2008 were included. OP was defined as the identification (by a consultant radiologist) of a pneumothorax on TCT that had not been detected on supine CXR. OPs were classified by laterality (unilateral/bilateral) and location (apical, basal, non apical/basal). The size of pneumothoraces, severity of injury [including number of associated thoracic injuries and injury severity score (ISS)], length of hospital stay and mortality were compared between groups. The need for tube thoracostomy and clinical outcome were also analysed. Patients with bilateral OPs (N=8) had significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 23, p=0.02) and longer hospital stay (median: 20 days vs. 11 days, p=0.01) than those with a unilateral OP (N=28). Basal OPs (N=7) were significantly larger than apical (N=10) and non-apical/basal Ops (N=11). Basal OPs were associated with significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23 days vs. 17 days, p=0.02) than apical Ops, which had higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23 days vs. 15 days, p=0.02) than non-apical/basal OPs. Non-apical/basal OPs were associated with more related injuries (median: 2 vs. 1, p=0.02) than apical OPs. All apical and non-apical/basal OPs were successfully managed expectantly without associated mortality. This TCT classification of OP is proposed to help clinicians to decide on subsequent management of the OP. Basal OPs are significantly larger in size, and both basal and bilateral OPs are associated with higher severity of injury and longer hospital stay. These groups of patient may benefit from prophylactic tube thoracostomy instead of conservative treatment. On the other hand, apical and non-apical/basal groups is smaller in size, less severely injured and thus can be successfully managed expectantly. Copyright © 2012 Elsevier Ltd. All rights reserved.

Automatic Pre-Hospital Vital Signs Waveform and Trend Data Capture Fills Quality Management, Triage and Outcome Prediction Gaps

PubMed Central

Mackenzie, Colin F; Hu, Peter; Sen, Ayan; Dutton, Rick; Seebode, Steve; Floccare, Doug; Scalea, Tom

2008-01-01

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study. Abnormalities of pulse oximeter oxygen saturation (< 95%) and validated heart rate (> 100/min) showed better prediction of injury severity, need for immediate blood transfusion, intra-abdominal surgery, tracheal intubation and chest tube insertion than Trauma Registry data or Pre-hospital provider estimations. Automated means of data collection introduced the potential for more accurate and objective reporting of patient vital signs helping in evaluating quality of care and establishing performance indicators and benchmarks. Addition of novel and existing non-invasive monitors and waveform analyses could make the pulse oximeter the decision aid of choice to improve trauma patient triage. PMID:18999022

Do we need 3D tube current modulation information for accurate organ dosimetry in chest CT? Protocols dose comparisons.

PubMed

Lopez-Rendon, Xochitl; Zhang, Guozhi; Coudyzer, Walter; Develter, Wim; Bosmans, Hilde; Zanca, Federica

2017-11-01

To compare the lung and breast dose associated with three chest protocols: standard, organ-based tube current modulation (OBTCM) and fast-speed scanning; and to estimate the error associated with organ dose when modelling the longitudinal (z-) TCM versus the 3D-TCM in Monte Carlo simulations (MC) for these three protocols. Five adult and three paediatric cadavers with different BMI were scanned. The CTDI vol of the OBTCM and the fast-speed protocols were matched to the patient-specific CTDI vol of the standard protocol. Lung and breast doses were estimated using MC with both z- and 3D-TCM simulated and compared between protocols. The fast-speed scanning protocol delivered the highest doses. A slight reduction for breast dose (up to 5.1%) was observed for two of the three female cadavers with the OBTCM in comparison to the standard. For both adult and paediatric, the implementation of the z-TCM data only for organ dose estimation resulted in 10.0% accuracy for the standard and fast-speed protocols, while relative dose differences were up to 15.3% for the OBTCM protocol. At identical CTDI vol values, the standard protocol delivered the lowest overall doses. Only for the OBTCM protocol is the 3D-TCM needed if an accurate (<10.0%) organ dosimetry is desired. • The z-TCM information is sufficient for accurate dosimetry for standard protocols. • The z-TCM information is sufficient for accurate dosimetry for fast-speed scanning protocols. • For organ-based TCM schemes, the 3D-TCM information is necessary for accurate dosimetry. • At identical CTDI vol , the fast-speed scanning protocol delivered the highest doses. • Lung dose was higher in XCare than standard protocol at identical CTDI vol .

Screening protocols to monitor respiratory status in primary immunodeficiency disease: findings from a European survey and subclinical infection working group.

PubMed

Jolles, S; Sánchez-Ramón, S; Quinti, I; Soler-Palacín, P; Agostini, C; Florkin, B; Couderc, L-J; Brodszki, N; Jones, A; Longhurst, H; Warnatz, K; Haerynck, F; Matucci, A; de Vries, E

2017-11-01

Many patients with primary immunodeficiency (PID) who have antibody deficiency develop progressive lung disease due to underlying subclinical infection and inflammation. To understand how these patients are monitored we conducted a retrospective survey based on patient records of 13 PID centres across Europe, regarding the care of 1061 adult and 178 paediatric patients with PID on immunoglobulin (Ig) G replacement. The most common diagnosis was common variable immunodeficiency in adults (75%) and hypogammaglobulinaemia in children (39%). The frequency of clinic visits varied both within and between centres: every 1-12 months for adult patients and every 3-6 months for paediatric patients. Patients diagnosed with lung diseases were more likely to receive pharmaceutical therapies and received a wider range of therapies than patients without lung disease. Variation existed between centres in the frequency with which some clinical and laboratory monitoring tests are performed, including exercise tests, laboratory testing for IgG subclass levels and specific antibodies, and lung function tests such as spirometry. Some tests were carried out more frequently in adults than in children, probably due to difficulties conducting these tests in younger children. The percentage of patients seen regularly by a chest physician, or who had microbiology tests performed following chest and sinus exacerbations, also varied widely between centres. Our survey revealed a great deal of variation across Europe in how frequently patients with PID visit the clinic and how frequently some monitoring tests are carried out. These results highlight the urgent need for consensus guidelines on how to monitor lung complications in PID patients. © 2017 The Authors. Clinical and Experimental Immunology published by John Wiley & Sons Ltd on behalf of British Society for Immunology.

Screening protocols to monitor respiratory status in primary immunodeficiency disease: findings from a European survey and subclinical infection working group

PubMed Central

Sánchez‐Ramón, S.; Quinti, I.; Soler‐Palacín, P.; Agostini, C.; Florkin, B.; Couderc, L.‐J.; Brodszki, N.; Jones, A.; Longhurst, H.; Warnatz, K.; Haerynck, F.; Matucci, A.; de Vries, E.

2017-01-01

Summary Many patients with primary immunodeficiency (PID) who have antibody deficiency develop progressive lung disease due to underlying subclinical infection and inflammation. To understand how these patients are monitored we conducted a retrospective survey based on patient records of 13 PID centres across Europe, regarding the care of 1061 adult and 178 paediatric patients with PID on immunoglobulin (Ig) G replacement. The most common diagnosis was common variable immunodeficiency in adults (75%) and hypogammaglobulinaemia in children (39%). The frequency of clinic visits varied both within and between centres: every 1–12 months for adult patients and every 3–6 months for paediatric patients. Patients diagnosed with lung diseases were more likely to receive pharmaceutical therapies and received a wider range of therapies than patients without lung disease. Variation existed between centres in the frequency with which some clinical and laboratory monitoring tests are performed, including exercise tests, laboratory testing for IgG subclass levels and specific antibodies, and lung function tests such as spirometry. Some tests were carried out more frequently in adults than in children, probably due to difficulties conducting these tests in younger children. The percentage of patients seen regularly by a chest physician, or who had microbiology tests performed following chest and sinus exacerbations, also varied widely between centres. Our survey revealed a great deal of variation across Europe in how frequently patients with PID visit the clinic and how frequently some monitoring tests are carried out. These results highlight the urgent need for consensus guidelines on how to monitor lung complications in PID patients. PMID:28708268

Trauma deaths in the first hour: are they all unsalvageable injuries?

PubMed

MacLeod, Jana B A; Cohn, Stephen M; Johnson, E William; McKenney, Mark G

2007-02-01

With the advent of trauma systems, time to definitive care has been decreased. We hypothesized that a subset of patients who are in extremis from the time of prehospital transport to arrival at the trauma center, and who ultimately die early after arrival, may in fact have a potentially salvageable single-organ injury. We reviewed all deaths that occurred in the first hour after hospital admission. Trauma registry, medical records, and autopsy reports for 556 patients were evaluated. The median time to arrival was 39 minutes, and the median Injury Severity Score was 29. Blunt injuries (53%) were most commonly auto-accident injuries (134 of 285 patients; 47%). Penetrating wounds (42%) were mostly gunshot wounds to the chest (73 of 233 patients; 31%). For patients with initial vital signs, the most common cause of death was isolated brain injury (26 patients; 28%). Possibly survivable injuries (single organ or vessel) occurred in 35 (38%) patients, of which 4 were isolated spleen injuries (4%). Some patients with potentially survivable single organ injuries did not have associated head injuries. An aggressive approach is warranted on patients with detectable vital signs on at least one occasion in the field but who arrive at the trauma center in extremis.

Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase.

PubMed

Chico-Fernández, M; Llompart-Pou, J A; Guerrero-López, F; Sánchez-Casado, M; García-Sáez, I; Mayor-García, M D; Egea-Guerrero, J; Fernández-Ortega, J F; Bueno-González, A; González-Robledo, J; Servià-Goixart, L; Roldán-Ramírez, J; Ballesteros-Sanz, M Á; Tejerina-Alvarez, E; García-Fuentes, C; Alberdi-Odriozola, F

2016-01-01

To describe the characteristics and management of severe trauma disease in Spanish Intensive Care Units (ICUs). Registry of trauma in the ICU (RETRAUCI). Pilot phase. A prospective, multicenter registry. Thirteen Spanish ICUs. Patients with trauma disease admitted to the ICU. None. Epidemiology, out-of-hospital attention, registry of injuries, resources utilization, complications and outcome were evaluated. Patients, n=2242. Mean age 47.1±19.02 years. Males 79%. Blunt trauma 93.9%. Injury Severity Score 22.2±12.1, Revised Trauma Score 6.7±1.6. Non-intentional in 84.4% of the cases. The most common causes of trauma were traffic accidents followed by pedestrian and high-energy falls. Up to 12.4% were taking antiplatelet medication or anticoagulants. Almost 28% had a suspected or confirmed toxic influence in trauma. Up to 31.5% required an out-of-hospital artificial airway. The time from trauma to ICU admission was 4.7±5.3hours. At ICU admission, 68.5% were hemodynamically stable. Brain and chest injuries predominated. A large number of complications were documented. Mechanical ventilation was used in 69.5% of the patients (mean 8.2±9.9 days), of which 24.9% finally required a tracheostomy. The median duration of stay in the ICU and in hospital was 5 (range 3-13) and 9 (5-19) days, respectively. The ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16.0%. The pilot phase of the RETRAUCI offers a first impression of the epidemiology and management of trauma disease in Spanish ICUs. Copyright © 2015 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Case report: aortic dissection and cystic medial degeneration in a 24-year-old without Marfan syndrome.

PubMed

Caraang, Chris; El-Bialy, Adel

2004-12-01

The effective management of aortic dissection relies heavily on a high index of suspicion followed by timely definitive diagnosis. Young adults without a history of blunt trauma who are not at risk for atherosclerotic disease may lower this suspicion. We present a 24-year-old patient with complaints of chest pain who presented in multiple urgent care clinics and emergency departments. With a normal chest radiograph, he was repeatedly discharged home on analgesics until a loud murmur was heard. An echocardiogram revealed a dilated aortic root with an intimal flap consistent with a type II dissection. After surgical aortic repair with a Bentall procedure, he was discharged with complete relief of symptoms. Histologic reports revealed cystic medial degeneration. Physical examinations did not demonstrate the phenotypic manifestations of Marfan syndrome. This case illustrates the importance of cardiac auscultation when assessing an individual with chest pain, even with a low likelihood for alteration in arterial structure, and the maintenance of a high index of clinical suspicion despite a normal chest radiograph. We consider this case to be of interest because of its rarity in a 24-year-old.

Noonan syndrome.

PubMed

Turner, Anne M

2014-10-01

Noonan syndrome is a common autosomal dominant condition, readily recognisable in childhood. It is characterised by a pattern of typical facial dysmorphism and malformations including congenital cardiac defects, short stature, abnormal chest shape, broad or webbed neck, and a variable learning disability. Mildly affected adults may not be diagnosed until the birth of a more obviously affected child. The phenotype is highly variable. Important progress in understanding the molecular basis of this and other related conditions was made in 2001 when germline mutations in the PTPN11 gene were found to account for ∼50% of cases. Since then, mutations in additional genes in the rat sarcoma (RAS) pathway have been identified in a proportion of the remainder. Molecular confirmation of diagnosis is now possible for many families and has become increasingly important in guiding management. Increased awareness by paediatricians will lead to earlier diagnosis, and provide patients and their families with accurate genetic counselling, including options when planning pregnancy. © 2011 The Author. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications.

PubMed

Iacobellis, Francesca; Ierardi, Anna M; Mazzei, Maria A; Magenta Biasina, Alberto; Carrafiello, Gianpaolo; Nicola, Refky; Scaglione, Mariano

2016-01-01

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

Sonography of occult rib and costal cartilage fractures: a case series.

PubMed

Mattox, Ross; Reckelhoff, Kenneth E; Welk, Aaron B; Kettner, Norman W

2014-06-01

The purpose of this case series is to describe the use of diagnostic ultrasound (US) in the detection of occult rib and costal cartilage fractures presenting as chest wall pain to a chiropractic clinic. Three patients presented with chest wall pain and tenderness. Two of the patients presented with acute chest wall injury and 1 carried a previous diagnosis of rib fracture after trivial trauma 2 months earlier. Diagnostic US was selected as a non-ionizing imaging tool for these patients after negative digital radiography studies. All fractures were considered isolated as there was no associated injury, such as pneumothorax. Both of the acute cases were followed up to complete healing (evidence of osseous union) using US. All patients eventually achieved pain-free status. In these cases, US was more sensitive than radiography for diagnosing these cases of acute rib and costal cartilage fractures. Early recognition of rib injury could avoid potential complications from local manipulative therapy.

(Video Assisted) thoracoscopic surgery: Getting started

PubMed Central

Molnar, Tamas F

2007-01-01

Thoracoscopic surgery without or with video assistance (VATS) is simpler and easier to learn as it seems to be. Potential benefits of the procedure in rural surgical environment are outlined while basic requirements and limitations are listed. Thoracoscopy kit, thoracotomy tray at hand, patient monitoring, proper drainage system, pain control and access to chest physiotherapy are the basic requirements. Having headlight, bronchoscope, Ligasure and mechanical staplers offer clear advantages but they are not indispensable. Exploration and evacuation of pleural space, pleurodesis, surgery for Stage I and II thoracic empyema are evidenced fields of VATS procedures. Some of the cases can be performed under controlled local anesthesia. Acute chest trauma cannot be recommended for VATS treatment. Lung cancer is out of the scope of rural surgery. PMID:19789679

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: does size matter? Chest drains in haemothorax following trauma.

PubMed

2013-11-01

A short-cut review was carried out to establish whether the size of chest drain inserted is important in haemothoraces. Forty-nine papers were found of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 4. The clinical bottom line is that while the available evidence suggests that small bore drains may be as effective as large bore drains in resolving traumatic haemothoraces without additional complications, there is insufficient evidence currently available to recommend a change to standard practice (ie, large bore drains).

Soft tissue mass of the chest wall as the sole manifestation of brucellosis in a 7-year-old boy.

PubMed

Al-Ayed, Mohammed S; Bin-Hussain, Ibrahim Z; Al Hajjar, Sami; Al Nassar, Saleh

2011-01-01

We report the case of a child who presented with a subcutaneous mass on the left side of the chest wall of one month's duration. The mass was painful and increasing in size over time. He had a history of weight loss and a decrease in appetite, but no history of fever or trauma. He had ingested raw camel milk, but had no history of contact with animals. He was diagnosed by the standard tube agglutination titer and tissue culture for brucellosis, treated with surgery and three months of antibrucella antibiotics. The report includes a brief review of the current pediatric literature to familiarize pediatricians with this uncommon presentation.

Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis.

PubMed

Alrajab, Saadah; Youssef, Asser M; Akkus, Nuri I; Caldito, Gloria

2013-09-23

Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax. We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax. We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used. Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.

Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients.

PubMed

Maxfield, Mark W; Schuster, Kevin M; McGillicuddy, Edward A; Young, Calvin J; Ghita, Monica; Bokhari, S A Jamal; Oliva, Isabel B; Brink, James A; Davis, Kimberly A

2012-12-01

A recent study showed that computed tomographic (CT) scans contributed 93% of radiation exposure of 177 patients admitted to our Level I trauma center. Adaptive statistical iterative reconstruction (ASIR) is an algorithm that reduces the noise level in reconstructed images and therefore allows the use of less ionizing radiation during CT scans without significantly affecting image quality. ASIR was instituted on all CT scans performed on trauma patients in June 2009. Our objective was to determine if implementation of ASIR reduced radiation dose without compromising patient outcomes. We identified 300 patients activating the trauma system before and after the implementation of ASIR imaging. After applying inclusion criteria, 245 charts were reviewed. Baseline demographics, presenting characteristics, number of delayed diagnoses, and missed injuries were recorded. The postexamination volume CT dose index (CTDIvol) and dose-length product (DLP) reported by the scanner for CT scans of the chest, abdomen, and pelvis and CT scans of the brain and cervical spine were recorded. Subjective image quality was compared between the two groups. For CT scans of the chest, abdomen, and pelvis, the mean CTDIvol (17.1 mGy vs. 14.2 mGy; p < 0.001) and DLP (1,165 mGy·cm vs. 1,004 mGy·cm; p < 0.001) was lower for studies performed with ASIR. For CT scans of the brain and cervical spine, the mean CTDIvol (61.7 mGy vs. 49.6 mGy; p < 0.001) and DLP (1,327 mGy·cm vs. 1,067 mGy·cm; p < 0.001) was lower for studies performed with ASIR. There was no subjective difference in image quality between ASIR and non-ASIR scans. All CT scans were deemed of good or excellent image quality. There were no delayed diagnoses or missed injuries related to CT scanning identified in either group. Implementation of ASIR imaging for CT scans performed on trauma patients led to a nearly 20% reduction in ionizing radiation without compromising outcomes or image quality. Therapeutic study, level IV.

Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients

PubMed Central

Maxfield, Mark W.; Schuster, Kevin M.; McGillicuddy, Edward A.; Young, Calvin J.; Ghita, Monica; Bokhari, S.A. Jamal; Oliva, Isabel B.; Brink, James A.; Davis, Kimberly A.

2013-01-01

BACKGROUND A recent study showed that computed tomographic (CT) scans contributed 93% of radiation exposure of 177 patients admitted to our Level I trauma center. Adaptive statistical iterative reconstruction (ASIR) is an algorithm that reduces the noise level in reconstructed images and therefore allows the use of less ionizing radiation during CT scans without significantly affecting image quality. ASIR was instituted on all CT scans performed on trauma patients in June 2009. Our objective was to determine if implementation of ASIR reduced radiation dose without compromising patient outcomes. METHODS We identified 300 patients activating the trauma system before and after the implementation of ASIR imaging. After applying inclusion criteria, 245 charts were reviewed. Baseline demographics, presenting characteristics, number of delayed diagnoses, and missed injuries were recorded. The postexamination volume CT dose index (CTDIvol) and dose-length product (DLP)reported by the scanner for CT scans of the chest, abdomen, and pelvis and CT scans of the brain and cervical spine were recorded. Subjective image quality was compared between the two groups. RESULTS For CT scans of the chest, abdomen, and pelvis, the mean CTDIvol(17.1 mGy vs. 14.2 mGy; p < 0.001) and DLP (1,165 mGy·cm vs. 1,004 mGy·cm; p < 0.001) was lower for studies performed with ASIR. For CT scans of the brain and cervical spine, the mean CTDIvol(61.7 mGy vs. 49.6 mGy; p < 0.001) and DLP (1,327 mGy·cm vs. 1,067 mGy·cm; p < 0.001) was lower for studies performed with ASIR. There was no subjective difference in image quality between ASIR and non-ASIR scans. All CT scans were deemed of good or excellent image quality. There were no delayed diagnoses or missed injuries related to CT scanning identified in either group. CONCLUSION Implementation of ASIR imaging for CT scans performed on trauma patients led to a nearly 20% reduction in ionizing radiation without compromising outcomes or image quality. PMID:23147183

Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study.

PubMed

Berger, Rachel P; Parks, Sharyn; Fromkin, Janet; Rubin, Pamela; Pecora, Peter J

2015-04-01

To assess the accuracy of an International Classification of Diseases (ICD) code-based operational case definition for abusive head trauma (AHT). Subjects were children <5 years of age evaluated for AHT by a hospital-based Child Protection Team (CPT) at a tertiary care paediatric hospital with a completely electronic medical record (EMR) system. Subjects were designated as non-AHT traumatic brain injury (TBI) or AHT based on whether the CPT determined that the injuries were due to AHT. The sensitivity and specificity of the ICD-based definition were calculated. There were 223 children evaluated for AHT: 117 AHT and 106 non-AHT TBI. The sensitivity and specificity of the ICD-based operational case definition were 92% (95% CI 85.8 to 96.2) and 96% (95% CI 92.3 to 99.7), respectively. All errors in sensitivity and three of the four specificity errors were due to coder error; one specificity error was a physician error. In a paediatric tertiary care hospital with an EMR system, the accuracy of an ICD-based case definition for AHT was high. Additional studies are needed to assess the accuracy of this definition in all types of hospitals in which children with AHT are cared for. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Reverse radial artery flap for soft tissue defects of hand in pediatric age group.

PubMed

Cheema, Saeed Ashraf; Talaat, Nabeela

2009-01-01

To highlight the usefulness of reverse radial artery flap in covering various soft tissue defects of hand in paediatric age group. A total of 16 reverse radial artery flaps were utilized in a period of three years to cover various soft tissue defects of hand for paediatric age group patients. The age ranged from 5-18 years. The two common causes of soft tissue defects in this series were mechanical trauma and fireworks trauma with five cases in each group. Three of the cases were burn victims and other two presented with earth quake injuries. One patient had wound because of road traffic accident. Soft tissue defects of palm were covered with this flap in eight cases while in three cases it was wrapped around the thumb. First web space defects were covered with this flap in two cases. Two cases required coverage of amputation stump at transmetacarpal level and yet another required a big flap to cover the soft tissue defects at palm, dorsum and thumb. Donor site was covered with split skin graft in all cases but one, which was closed primarily. We had partial loss of flap in one case. Grafted donor sites healed uneventfully and were quite acceptable to the patients in due course of time. Reverse radial artery flap has a quite long arc of rotation which brings it great ease to cover the soft tissue defects of various areas of hand like palm, dorsum, first web space and thumb.

[Cohort study on the prevalence and risk factors of late pulmonary complications in adults following a closed minor chest trauma].

PubMed

Plourde, Miville; Émond, Marcel; Lavoie, André; Guimont, Chantal; Le Sage, Natalie; Chauny, Jean-Marc; Bergeron, Éric; Vanier, Laurent; Moore, Lynne; Allain-Boulé, Nadine; Fratu, Ramona-Florina; Dufresne, Maryline

2013-11-01

The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray. Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Protocol for a multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL trial.

PubMed

Battle, Ceri; Abbott, Zoe; Hutchings, Hayley A; O'Neill, Claire; Groves, Sam; Watkins, Alan; Lecky, Fiona E; Jones, Sally; Gagg, James; Body, Richard; Evans, Philip A

2017-07-10

A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). A definitive randomised controlled trial (impact trial) is required to assess the clinical and cost effectiveness of the new model before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design. This feasibility trial is designed to test the methods of a multicentre, cluster-randomised (stepped- wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a 5-month period; in the initial period acting as the controls (normal care), and in the second period acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a 6-week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory). Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed. Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Patient recruitment will commence in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal , presentation at appropriate conferences and to stakeholders at professional meetings. ISRCTN95571506; Pre-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

12 A multi-centre randomised feasibility study evaluating the impact of a prognostic model for management of blunt chest wall trauma patients: stumbl trial.

PubMed

Battle, Ceri; Hutchings, Hayley; Abbott, Zoe; O'neill, Claire; Groves, Sam; Watkins, Alan; Lecky, Fiona; Jones, Sally; Gagg, James; Body, Rick; Evans, Phillip

2017-12-01

A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the Emergency Department (ED). A definitive randomised controlled trial (impact trial), is required to assess the clinical and cost effectiveness of the new model, before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design. This feasibility trial is designed to test the methods of a multi-centre, cluster-randomised (stepped wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a five month period; in the initial period acting as the controls (normal care) and the second period, acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a six week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory).Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed. Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Health Care Research Wales Research Permissions and the HRA have granted approval for the study. Patient recruitment commenced in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at Professional Meetings. © 2017, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study.

PubMed

Caragounis, Eva-Corina; Fagevik Olsén, Monika; Pazooki, David; Granhed, Hans

2016-01-01

Multiple rib fractures and unstable thoracic cage injuries are common in blunt trauma. Surgical management of rib fractures has received increasing attention in recent years and the aim of this 1-year, prospective study was to assess the long-term effects of surgery. Fifty-four trauma patients with median Injury Severity Score 20 (9-66) and median New Injury Severity Score 34 (16-66) who presented with multiple rib fractures and flail chest, and underwent surgical stabilization with plate fixation were recruited. Patients responded to a standardized questionnaire concerning pain, local discomfort, breathlessness and use of analgesics and health-related quality of life (EQ-5D-3 L) questionnaire at 6 weeks, 3 months, 6 months and 1 year. Lung function, breathing movements, range of motion and physical function were measured at 3 months, 6 months and 1 year. Symptoms associated with pain, breathlessness and use of analgesics significantly decreased from 6 weeks to 1 year following surgery. After 1 year, 13 % of patients complained of pain at rest, 47 % had local discomfort and 9 % used analgesics. The EQ-5D-3 L index increased from 0.78 to 0.93 and perceived overall health state increased from 60 to 90 % (p < 0.0001) after 6 weeks to 1 year. Lung function improved significantly with predicted Forced vital capacity and Peak expiratory flow increasing from 86 to 106 % (p = 0.0002) and 81 to 110 % (p < 0.0001), respectively, from 3 months to 1 year after surgery. Breathing movements and range of motion tended to improve over time. Physical function improved significantly over time and the median Disability rating index was 0 after 1 year. Patients with multiple rib fractures and flail chest show a gradual improvement in symptoms associated with pain, quality of life, mobility, disability and lung function over 1 year post surgery. Therefore, the final outcome of surgery cannot be assessed before 1 year post-operatively.

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience.

PubMed

Chen, Jacob; Nadler, Roy; Schwartz, Dagan; Tien, Homer; Cap, Andrew P; Glassberg, Elon

2015-06-01

Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDF-MC experience with chest decompression by NT. We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted. During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT. Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT.

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

PubMed Central

Chen, LTC Jacob; Nadler, Capt Roy; Schwartz, Maj Dagan; Tien, Col Homer; Cap, LTC Andrew P.; Glassberg, Col Elon

2015-01-01

Background Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDF-MC experience with chest decompression by NT. Methods We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted. Results During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT. Conclusion Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT. PMID:26100771

American Association for the Surgery of Trauma Organ Injury Scaling: 50th anniversary review article of the Journal of Trauma.

PubMed

Moore, Ernest E; Moore, Frederick A

2010-12-01

The purpose of a scaling system for specific injuries is to provide a common language to facilitate the clinical decisions and the investigative basis for this decision making. This brief overview describes the evolution of the Organ Injury Scaling (OIS) system developed by the American Association for the Surgery of Trauma. The OIS system is based on the magnitude of anatomic disruption and is graded as 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), 5 (massive), and 6 (lethal). To date, the American Association for the Surgery of Trauma OIS system has been developed for visceral and vascular injuries of the neck, chest, abdomen, and extremities. The fundamental objective of OIS is to provide a common language to describe specific organ injuries. The primary purpose of OIS is to facilitate clinical decision making and the necessary research endeavors to improve this process. A good example of this concept is the tumor, node, metastasis classification for solid organ malignancies: a system used worldwide to guide patient care and clinical investigation.

Radionuclide evaluation of lung trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lull, R.J.; Tatum, J.L.; Sugerman, H.J.

1983-07-01

Nuclear medicine imaging procedures can play a significant role in evaluating the pulmonary complications that are seen in trauma patients. A quantitative method for measuring increased pulmonary capillary permeability that uses Tc-99m HSA allows early diagnosis of acute respiratory distress syndrome (ARDS) and accurately differentiates this condition from pneumonia or cardiogenic pulmonary edema. This technique may be of great value in following the response to therapy. The use of 133Xe to diagnose inhalation injury remains an important diagnostic tool, particularly at hospitals with specialized burn units. Regional decreases in ventilation-perfusion images reliably localize aspirated foreign bodies. Radionuclide techniques that aremore » used to demonstrate gastropulmonary aspiration remain controversial and require further clinical evaluation. Pulmonary perfusion imaging, although nonspecific, may provide the earliest clue for correct diagnosis of fat embolism, air embolism, contusion, or laceration. Furthermore, the possibility of perfusion abnormality due to these uncommon conditions must be remembered whenever trauma patients are evaluated for pulmonary thromboembolism with scintigraphy. Occasionally, liver or spleen scintigraphy may be the most appropriate procedure when penetrating chest trauma also involves these subdiaphragmatic organs.« less

[Bony injuries of the thoracic cage in multiple trauma : Incidence, concomitant injuries, course and outcome].

PubMed

Schulz-Drost, S; Oppel, P; Grupp, S; Krinner, S; Langenbach, A; Lefering, R; Mauerer, A

2016-12-01

Thoracic trauma is considered to be responsible for 25 % of fatalities in multiple trauma and is a frequent injury with an incidence of 50 %. In addition to organ injuries, severe injuries to the bony parts of the thorax also occur and these injuries are described very differently mostly based on single center data. The focus of this study was on a holistic presentation of the prevalence and the incidence of thoracic trauma in patients with multiple trauma from the data of the large collective of the TraumaRegister DGU® (TR-DGU) with the objective of an analysis of concomitant injuries, therapy options and outcome parameters. A retrospective analysis was carried out based on the data set of the TR-DGU from the years 2009-2013. Inclusion criteria were an injury severity scale (ISS) score ≥ 16 and primary admission to a trauma center but isolated craniocerebral injury was an exclusion criterium. Patients were separated into two groups: those with rib fractures (RF) and those with flail chest (FC). A total of 21,741 patients met the inclusion criteria including 10,474 (48.2 %) suffering from either RF or FC. The mean age was 49.8 ± 19.9 years in the RF group and 54.1 ± 18.2 years in the FC group. Approximately 25 % were female in both groups, 98.1 % were blunt force injuries and the median ISS was 28.0 ± 11.2 in RF and 35.1 ± 14.2 in FC. Shock, insertion of a chest tube, (multi) organ failure and fatality rates were significantly higher in the FC group as were concomitant thoracic injuries, such as pneumothorax and hemothorax. Sternal fractures without rib fractures were less common (3.8 %) than concomitant in the RF (10.1 %) and FC (14 %) groups, as were concomitant fractures of the clavicle and the scapula. Out of all patients 32.6 % showed fractures of the thoracolumbar spine, 26.5 % without rib fractures, 36.6-38.6 % with rib fractures or monolateral FC and 48.6 % concomitant to bilateral FC. Thoracotomy was carried out only in isolated cases in RF and in 10.2 % of the FC group. Operative stabilization of the thoracic cage was carried out in 3.9-9.1 % of patients in the RF group and in 17.9-23.9 % in the FC group.

[Polytrauma in children and adolescents. Choice of the primary care clinic and importance of pediatric traumatology competence centers].

PubMed

Debus, F; Lefering, R; Frink, M; Kühne, C; Mand, C; Ruchholtz, S

2015-05-01

The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment. All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality. At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC). The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

Hypertonic saline in paediatric traumatic brain injury: a review of nine years' experience with 23.4% hypertonic saline as standard hyperosmolar therapy.

PubMed

Piper, B J; Harrigan, P W

2015-03-01

We describe the protocolised use of 23.4% hypertonic saline solution (HTS) for intracranial hypertension in the context of traumatic brain injury in the paediatric population. This study represents the largest published data on the use of 23.4% HTS in the paediatric population. In this retrospective cohort, we focus on the efficacy, biochemical and metabolic consequences of 23.4% HTS administration in a Level 1 paediatric trauma centre. Mortality in the first seven days was 6% (2/32) with a mean intensive care unit length-of-stay of ten days (range 2 to 25, standard deviation [SD] 6). All-cause hospital mortality was 6%, with no deaths after the seven-day study period. Mean intracranial pressure (ICP) response to HTS was 10 mmHg (range 1 to 30, SD 8). For biochemistry data, the mean highest daily serum sodium was 148 mmol/l (139 to 161, SD 6), mean highest serum chloride was 115 mmol/l (range 101 to 132, SD 8) with matched mean serum base excess of -1.5 mmol/l (range 2 to -8, SD 3) and mean peak serum creatinine was 73 mmol/l (range 32 to 104, SD 32). Glasgow outcome scores of >3 (independent function) were achieved in 74% of patients. We describe the use of 23.4% HTS, demonstrating it to be a practical and efficacious method of delivering osmoles and may be advantageous in minimising total fluid volume. Thus, the bolus versus infusion debate may best be served via combining both approaches.

Reduction in radiation doses from paediatric CT scans in Great Britain.

PubMed

Lee, Choonsik; Pearce, Mark S; Salotti, Jane A; Harbron, Richard W; Little, Mark P; McHugh, Kieran; Chapple, Claire-Louise; Berrington de Gonzalez, Amy

2016-01-01

Although CT scans provide great medical benefits, concerns have been raised about the magnitude of possible associated cancer risk, particularly in children who are more sensitive to radiation than adults. Unnecessary high doses during CT examinations can also be delivered to children, if the scan parameters are not adjusted for patient age and size. We conducted the first survey to directly assess the trends in CT scan parameters and doses for paediatric CT scans performed in Great Britain between 1978 and 2008. We retrieved 1073 CT film sets from 36 hospitals. The patients were 0-19 years old, and CT scans were conducted between 1978 and 2008. We extracted scan parameters from each film including tube current-time product [milliampere seconds (mAs)], tube potential [peak kilovoltage (kVp)] and manufacturer and model of the CT scanner. We estimated the mean mAs for head and trunk (chest and abdomen/pelvis) scans, according to patient age (0-4, 5-9, 10-14 and 15-19 years) and scan year (<1990, 1990-1994, 1995-1999 and ≥2000), and then derived the volumetric CT dose index and estimated organ doses. For head CT scans, mean mAs decreased by about 47% on average from before 1990 to after 2000, with the decrease starting around 1990. The mean mAs for head CTs did not vary with age before 1990, whereas slightly lower mAs values were used for younger patients after 1990. Similar declines in mAs were observed for trunk CTs: a 46% decline on an average from before 1990 to after 2000. Although mean mAs for trunk CTs did not vary with age before 1990, the value varied markedly by age, from 63 mAs for age 0-4 years compared with 315 mAs for those aged >15 years after 2000. No material changes in kVp were found. Estimated brain-absorbed dose from head CT scans decreased from 62 mGy before 1990 to approximately 30 mGy after 2000. For chest CT scans, the lung dose to children aged 0-4 years decreased from 28 mGy before 1990 to 4 mGy after 2000. We found that mAs for head and trunk CTs was approximately halved starting around 1990, and age-specific mAs was generally used for paediatric scans after this date. These changes will have substantially reduced the radiation exposure to children from CT scans in Great Britain. The study shows that mAs and major organ doses for paediatric CT scans in Great Britain began to decrease around 1990.

Reduction in radiation doses from paediatric CT scans in Great Britain

PubMed Central

Pearce, Mark S; Salotti, Jane A; Harbron, Richard W; Little, Mark P; McHugh, Kieran; Chapple, Claire-Louise; Berrington de Gonzalez, Amy

2016-01-01

Objective: Although CT scans provide great medical benefits, concerns have been raised about the magnitude of possible associated cancer risk, particularly in children who are more sensitive to radiation than adults. Unnecessary high doses during CT examinations can also be delivered to children, if the scan parameters are not adjusted for patient age and size. We conducted the first survey to directly assess the trends in CT scan parameters and doses for paediatric CT scans performed in Great Britain between 1978 and 2008. Methods: We retrieved 1073 CT film sets from 36 hospitals. The patients were 0–19 years old, and CT scans were conducted between 1978 and 2008. We extracted scan parameters from each film including tube current–time product [milliampere seconds (mAs)], tube potential [peak kilovoltage (kVp)] and manufacturer and model of the CT scanner. We estimated the mean mAs for head and trunk (chest and abdomen/pelvis) scans, according to patient age (0–4, 5–9, 10–14 and 15–19 years) and scan year (<1990, 1990–1994, 1995–1999 and ≥2000), and then derived the volumetric CT dose index and estimated organ doses. Results: For head CT scans, mean mAs decreased by about 47% on average from before 1990 to after 2000, with the decrease starting around 1990. The mean mAs for head CTs did not vary with age before 1990, whereas slightly lower mAs values were used for younger patients after 1990. Similar declines in mAs were observed for trunk CTs: a 46% decline on an average from before 1990 to after 2000. Although mean mAs for trunk CTs did not vary with age before 1990, the value varied markedly by age, from 63 mAs for age 0–4 years compared with 315 mAs for those aged >15 years after 2000. No material changes in kVp were found. Estimated brain-absorbed dose from head CT scans decreased from 62 mGy before 1990 to approximately 30 mGy after 2000. For chest CT scans, the lung dose to children aged 0–4 years decreased from 28 mGy before 1990 to 4 mGy after 2000. Conclusion: We found that mAs for head and trunk CTs was approximately halved starting around 1990, and age-specific mAs was generally used for paediatric scans after this date. These changes will have substantially reduced the radiation exposure to children from CT scans in Great Britain. Advances in knowledge: The study shows that mAs and major organ doses for paediatric CT scans in Great Britain began to decrease around 1990. PMID:26864156

Proper catheter selection for needle thoracostomy: a height and weight-based criteria.

PubMed

Powers, William F; Clancy, Thomas V; Adams, Ashley; West, Tonnya C; Kotwall, Cyrus A; Hope, William W

2014-01-01

Obesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy. We retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤ 18.5 kg/m2), normal weight (18.6-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), or obese (≥ 30 kg/m(2)). Three hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9]cm on the right and 6.3 [SD 1.9]cm on the left. As BMI increased, a statistically significant (p<0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups. As BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6-6.5 cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths. Copyright © 2013 Elsevier Ltd. All rights reserved.

Is trauma in Switzerland any different? epidemiology and patterns of injury in major trauma - a 5-year review from a Swiss trauma centre.

PubMed

Heim, C; Bosisio, F; Roth, A; Bloch, J; Borens, O; Daniel, R T; Denys, A; Oddo, M; Pasquier, M; Schmidt, S; Schoettker, P; Zingg, T; Wasserfallen, J B

2014-01-01

Switzerland, the country with the highest health expenditure per capita, is lacking data on trauma care and system planning. Recently, 12 trauma centres were designated to be reassessed through a future national trauma registry by 2015. Lausanne University Hospital launched the first Swiss trauma registry in 2008, which contains the largest database on trauma activity nationwide. Prospective analysis of data from consecutively admitted shock room patients from 1 January 2008 to 31 December 2012. Shock room admission is based on physiology and mechanism of injury, assessed by prehospital physicians. Management follows a surgeon-led multidisciplinary approach. Injuries are coded by Association for the Advancement of Automotive Medicine (AAAM) certified coders. Over the 5 years, 1,599 trauma patients were admitted, predominantly males with a median age of 41.4 years and median injury severity score (ISS) of 13. Rate of ISS >15 was 42%. Principal mechanisms of injury were road traffic (40.4%) and falls (34.4%), with 91.5% blunt trauma. Principal patterns were brain (64.4%), chest (59.8%) and extremity/pelvic girdle (52.9%) injuries. Severe (abbreviated injury scale [AIS] score ≥ 3) orthopaedic injuries, defined as extremity and spine injuries together, accounted for 67.1%. Overall, 29.1% underwent immediate intervention, mainly by orthopaedics (27.3%), neurosurgeons (26.3 %) and visceral surgeons (13.9%); 43.8% underwent a surgical intervention within the first 24 hours and 59.1% during their hospitalisation. In-hospital mortality for patients with ISS >15 was 26.2%. This is the first 5-year report on trauma in Switzerland. Trauma workload was similar to other European countries. Despite high levels of healthcare, mortality exceeds published rates by >50%. Regardless of the importance of a multidisciplinary approach, trauma remains a surgical disease and needs dedicated surgical resources.

Complications of tube thoracostomy in trauma

PubMed Central

Bailey, R

2000-01-01

Objective—To assess the complication rate of tube thoracostomy in trauma. To consider whether this rate is high enough to support a selective reduction in the indications for tube thoracostomy in trauma. Methods—A retrospective case series of all trauma patients who underwent tube thoracostomy during a 12 month period at a large UK teaching hospital with an accident and emergency (A&E) department seeing in excess of 125 000 new patients/year. These patients were identified using the hospital audit department computerised retrieval system supplemented by a hand search of both the data collected for the Major Trauma Outcome Study and the A&E admission unit log book. The notes were assessed with regard to the incidence of complications, which were divided into insertional, infective, and positional. Results—Fifty seven chest drains were placed in 47 patients over the 12 month period. Seven patients who died within 48 hours of drain insertion were excluded. The commonest indications for tube thoracostomy were pneumothorax (54%) and haemothorax (20%); 90% of tubes were placed as a result of blunt trauma. The overall complication rate of the procedure was 30%. There were no insertional complications and only one (2%) major complication, which was empyema thoracis. Conclusion—This study reveals no persuasive evidence to support a selective reduction in the indications for tube thoracostomy in trauma. A larger study to confirm or refute these findings must be performed before any change in established safe practice. PMID:10718232

Paid family leave's effect on hospital admissions for pediatric abusive head trauma.

PubMed

Klevens, Joanne; Luo, Feijun; Xu, Likang; Peterson, Cora; Latzman, Natasha E

2016-12-01

Paediatric abusive head trauma (AHT) is a leading cause of fatal child maltreatment among young children. Current prevention efforts have not been consistently effective. Policies such as paid parental leave could potentially prevent AHT, given its impacts on risk factors for child maltreatment. To explore associations between California's 2004 paid family leave (PFL) policy and hospital admissions for AHT, we used difference-in-difference analyses of 1995-2011 US state-level data before and after the policy in California and seven comparison states. Compared with seven states with no PFL policies, California's 2004 PFL showed a significant decrease in AHT admissions in both <1 and <2-year-olds. Analyses using additional data years and comparators could yield different results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Early Detection of Junctional Adhesion Molecule-1 (JAM-1) in the Circulation after Experimental and Clinical Polytrauma

PubMed Central

Denk, Stephanie; Wiegner, Rebecca; Hönes, Felix M.; Messerer, David A. C.; Radermacher, Peter; Kalbitz, Miriam; Braumüller, Sonja; McCook, Oscar; Gebhard, Florian; Weckbach, Sebastian; Huber-Lang, Markus

2015-01-01

Severe tissue trauma-induced systemic inflammation is often accompanied by evident or occult blood-organ barrier dysfunctions, frequently leading to multiple organ dysfunction. However, it is unknown whether specific barrier molecules are shed into the circulation early after trauma as potential indicators of an initial barrier dysfunction. The release of the barrier molecule junctional adhesion molecule-1 (JAM-1) was investigated in plasma of C57BL/6 mice 2 h after experimental mono- and polytrauma as well as in polytrauma patients (ISS ≥ 18) during a 10-day period. Correlation analyses were performed to indicate a linkage between JAM-1 plasma concentrations and organ failure. JAM-1 was systemically detected after experimental trauma in mice with blunt chest trauma as a driving force. Accordingly, JAM-1 was reduced in lung tissue after pulmonary contusion and JAM-1 plasma levels significantly correlated with increased protein levels in the bronchoalveolar lavage as a sign for alveolocapillary barrier dysfunction. Furthermore, JAM-1 was markedly released into the plasma of polytrauma patients as early as 4 h after the trauma insult and significantly correlated with severity of disease and organ dysfunction (APACHE II and SOFA score). The data support an early injury- and time-dependent appearance of the barrier molecule JAM-1 in the circulation indicative of a commencing trauma-induced barrier dysfunction. PMID:26556956

Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma

PubMed Central

Kemmler, Julia; Bindl, Ronny; McCook, Oscar; Wagner, Florian; Gröger, Michael; Wagner, Katja; Scheuerle, Angelika; Radermacher, Peter; Ignatius, Anita

2015-01-01

In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients. PMID:26147725

Intrathoracic pressure impulse predicts pulmonary contusion volume in ballistic blunt thoracic trauma.

PubMed

Prat, Nicolas; Rongieras, Frédéric; Voiglio, Eric; Magnan, Pascal; Destombe, Casimir; Debord, Eric; Barbillon, Franck; Fusai, Thierry; Sarron, Jean-Claude

2010-10-01

Blunt thoracic trauma including behind armour blunt trauma or impact from a less lethal kinetic weapon (LLKW) projectile may cause injuries, including pulmonary contusions that can result in potentially lethal secondary complications. These lung injuries may be caused by intrathoracic pressure waves. The aim of this study was to observe dynamic changes in intrathoracic hydrostatic pressure during ballistic blunt thoracic trauma and to find correlations between these hydrostatic pressure parameters (especially the impulse parameter) and physical damages. Thirty anesthetized pigs sustained a blunt thoracic trauma. In group 1 (n = 20), pigs were protected by a National Institute of Justice class III or IV bulletproof vest and shot with 7.62 NATO bullets. In group 2 (n = 10), pigs were shot by an LLKW. Intrathoracic pressure was recorded with an intraesophageal pressure sensor and three parameters were determined: intrathoracic maximum pressure, intrathoracic maximum pressure impulse (PI(max)), and the Pd.P/dt(max), derived from Viano's viscous criterion. Relative right lower lung lobe contusion volume was also measured. Different thoracic loading conditions were obtained. PI(max) best correlated with relative pulmonary contusion volume (R² = 0.64 and p < 0.0001). This result was homogenous for all experiments and was not related to the type of chest impact (LLKW-induced trauma or behind armour blunt trauma). The PI(max) is a good predictor of pulmonary contusion volume after ballistic blunt thoracic trauma. It is a useful criterion when the kinetic energy record or thoracic wall displacement data are unavailable, and the recording and calculation of this physical value are quite simple on animals.

Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques.

PubMed

Franke, I; Pingen, A; Schiffmann, H; Vogel, M; Vlajnic, D; Ganschow, R; Born, M

2014-07-01

Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the "two-thumbs" technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the "two-thumbs" CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation. Copyright © 2014 Elsevier Ltd. All rights reserved.

What is the effect of the weather on trauma workload? A systematic review of the literature.

PubMed

Ali, A M; Willett, K

2015-01-01

Hospital admission rates for a number of conditions have been linked to variations in the weather. It is well established that trauma workload displays significant seasonal variation. A reliable predictive model might enable targeting of high-risk groups for intervention and planning of hospital staff levels. To our knowledge there have been no systematic reviews of the literature on the relationship between weather and trauma workload, and predictive models have thus far been informed by the results of single studies. We conducted a systematic review of bibliographic databases and reference lists up to June 2014 to identify primary research papers assessing the effect of specified weather conditions including temperature, rainfall, snow, fog, hail, humidity and wind speed on trauma workload, defined as admission to hospital, fracture or a Road Traffic Accident (RTA) resulting in a seriously injured casualty or fatality. 11,083 papers were found through electronic and reference search. 83 full papers were assessed for eligibility. 28 met inclusion criteria and were included in the final review; 6 of these related to the effect of the weather on trauma admissions, one to ambulance call out for trauma, 13 to fracture rate and 8 to RTAs. Increased temperature is positively correlated with trauma admissions. The rate of distal radius fractures is more sensitive to adverse weather than the rate of hip fractures. Paediatric trauma, both in respect of trauma admissions and fracture rate, is more sensitive to the weather than adult trauma. Adverse weather influences both RTA frequency and severity, but the nature of the relationship is dependent upon the timecourse of the weather event and the population studied. Important methodological differences between studies limit the value of the existing literature in building consensus for a generalisable predictive model. Weather conditions may have a substantial effect on trauma workload independent of the effects of seasonal variation; the population studied and timecourse of weather events appear critical in determining this relationship. Methodological differences between studies limit the validity of conclusions drawn from analysis of the literature, and we identify a number of areas that future research might address. Copyright © 2015 Elsevier Ltd. All rights reserved.

Successful Surgical Stabilization of Rib Fractures Despite Candida Colonization of the Mediastinum.

PubMed

Ju, Tammy; Rivas, Lisbi; Sarani, Babak

2018-04-06

Pleural space or chest wall infection is a contraindication for surgical stabilization of rib fractures (SSRF) due to the risk of hardware infection. However, the exact degree of risk is uncertain. SSRF is associated with decreased need for mechanical ventilation and pneumonia. Here, we describe a poly-trauma patient with candida colonization of the mediastinum who successfully underwent SSRF. Copyright © 2018. Published by Elsevier Inc.

Spontaneous neonatal pneumomediastinum: the "spinnaker sail" sign.

PubMed

Lawal, T A; Glüer, S; Reismann, M; Dördelmann, M; Schirg, E; Ure, B

2009-02-01

Spontaneous pneumomediastinum is a rare condition in the newborn, not associated with identifiable trauma or mechanical ventilation. It is diagnosed by a combination of physical examination and confirmatory chest radiograph, with various recognized signs identifiable in this condition. We report the case of a male neonate, who had pneumomediastinum confirmed by the presence of a wind blown spinnaker sail sign and was managed conservatively. We also reviewed the literature.

Coronary Artery Fistula

DTIC Science & Technology

2007-04-01

man with a single episode of vague sub- sternal chest pain was referred for evaluation of possible coronary artery disease. His medical history was...significant for hypertension and type-II diabetes mellitus. The patient had no prior history of thoracic trauma or surgery. During an exercise...Figure 1A; oblique, Figure 1B), the left circumflex artery was identified by its black central lumen and noted to arise normally from the left main

[Etiology and diagnostic methods in vocal cord paralysis].

PubMed

Jørgensen, Gita; Clausen, Eva Wiinstedt; Mantoni, Margit Y; Misciattelli, Lorenzo; Balle, Viggo

2003-02-10

The etiology of vocal cord paralysis (VCP) is varied. There is lack of consensus regarding the choice of investigations to be used in the evaluation of VCP. The aim of this study was to establish the etiology, assess the diagnostic methods used in the evaluation, and outline an algorithm for future evaluation of unilateral vocal cord paralysis (UVCP). Charts of all patients (n = 94) with the diagnostic code of VCP were reviewed, and reexaminations were performed of patients in whom no etiology was found after the initial symptoms. The etiology of UVCP was neoplasm in 34%, surgical trauma in 12%, and miscellaneous causes in 54%. The etiology of bilateral vocal cord paralysis (BVCP) was neoplasm in 24%, surgical trauma in 24%, and miscellaneous causes in 52%. The reexaminations did not reveal any cancer diseases in the patients concerned. The most effective diagnostic method was CT-scanning while the least effective was thyroid scanning. Because cancer is a common cause of VCP a thorough evaluation is necessary. For UVCP we recommend history and physical examination, X-ray of the chest, ultrasonography of the neck, and CT-scanning of the superior mediastinum. If these prove negative, panendoscopy should be performed. Workup of patients with idiopathic VCP should include examination, X-ray of the chest at 6-month intervals, and annual CT-scanning for two years.

Concrete induced cardiac contusion.

PubMed Central

Curzen, N.; Brett, S.; Fox, K.

1997-01-01

A previously fit 22 year old man was struck in the chest by a concrete block dropped through the windscreen of his car while he was driving on the motorway. He suffered extensive chest wall trauma and lung contusion, which subsequently precipitated acute respiratory distress. On admission ECG showed right bundle branch block and left axis deviation. Three days later QRS duration was normal but there was anterior ST segment elevation and subsequent T wave change. There was a large rise in creatine kinase, and echocardiography revealed septal and apical hyokinesis as well as a mobile mass attached to the left side of the interventricular septum, which had the echogenic texture of myocardium. The patient had fixed perfusion defects in the areas of hypokinesis on thallium scanning but the coronary arteries were unobstructed at angiography. He was treated with warfarin in the short term and an angiotensin converting enzyme inhibitor in the longer term and has made an asymptomatic recovery. Outpatient echocardiography two months after the injury demonstrated some recovery in overall left ventricular systolic function and no evidence of the intracardiac mass. This case illustrates some of the typical features of non-fatal cardiac contusion associated with non-penetrating cardiac trauma, and was complicated by partial thickness avulsion of a strip of the myocardium in the interventricular septum. Images PMID:9391297

Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy

PubMed Central

Huang, Wen-Yen; Lu, I-Yin; Yang, Chyan; Chou, Yi-Pin; Lin, Hsing-Lin

2016-01-01

Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%, P = 0.061) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27, P = 0.029) and in the hospital (15.93 versus 23.17, P = 0.01) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS. PMID:27190987

An asymptomatic ruptured hepatic hydatid cyst case presenting with subdiaphragmatic gas in a traumatic patient.

PubMed

Eren, Suat; Yildirgan, Ilhan; Kantarci, A Mecit

2005-12-01

Hydatid disease presents as hydatid cysts primarily in the liver and lungs. Although hepatic hydatid cysts (HHCs) may be asymptomatic for many years, they may be symptomatic due to expansion, rupture, and pyogenic infection. Rupture of the HHC into the biliary tract is one of the most serious complications and is frequently related to overenlargement of the cyst or major trauma. Patients with this disease usually have jaundice or fever. We report an asymptomatic HHC ruptured after minor trauma. While the ruptured cyst was presented as the subdiaphragmatic gas on the chest radiography, it was detected as a large cyst with multiple daughter cysts on ultrasound, computed tomography scan, and magnetic resonance imaging.

[Hemopleuritis in closed thoracic injuries and multiple trauma].

PubMed

Kabanov, A N; Astafurov, V N; Blokh, E R

1991-09-01

In examination of 817 patients with closed chest injury and multiple trauma 57% of them were found to have obvious or latent hemopleuritis. According to the character of the primary damage and the developing pathophysiological changes, 3 forms of hemopleuritis were revealed: cardiac, pulmonary, and abdominal. A single complex of symptoms forms finally: pulmonary hypertension, venous stasis in the lungs, right-ventricular cardiac insufficiency. As a result, venous blood escapes through the lymph nodes, mainly those of the right lung, and together with the lymph flows in the dilated lymph vessels of the lungs into the pleural cavity. The differential-diagnostic signs of each form of hemopleuritis are pointed out, the prognostic criteria of their development are revealed, and the pathogenetically substantiated therapy is determined.

Induced hypothermia reduces the hepatic inflammatory response in a swine multiple trauma model.

PubMed

Fröhlich, Matthias; Hildebrand, Frank; Weuster, Matthias; Mommsen, Philipp; Mohr, Juliane; Witte, Ingo; Raeven, Pierre; Ruchholtz, Steffen; Flohé, Sascha; van Griensven, Martijn; Pape, Hans-Christoph; Pfeifer, Roman

2014-06-01

Mild therapeutic hypothermia following trauma has been introduced in several studies to reduce the posttraumatic inflammation and organ injury. In this study, we analyzed the effects of induced mild hypothermia (34°C) on the inflammation of the shock organs liver and kidney. In a porcine model of multiple trauma including blunt chest trauma, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of induced hypothermia on hepatic and renal damage and organ-specific inflammation were evaluated. A total of 40 pigs were randomly assigned to four groups, which were sham (anesthesia only) or trauma groups receiving either hypothermia or normothermia. The parameters analyzed were laboratory parameters (aspartate transaminase [AST], lactate dehydrogenase, urea, creatinine) as well as hepatic and renal cytokine expression determined by real-time polymerase chain reaction (interleukin 6 [IL-6], IL-8). Blinded analysis of histologic changes in the liver and kidney was performed. Fifteen and a half hours following combined trauma, hepatic cytokine expression and liver damage were significantly increased in animals with normothermia compared with the respective sham group. Hypothermia, however, resulted in a fivefold reduced hepatic expression of IL-8 (mean ± SE, 2.4 ± 1.3; p = 0.01) when compared with the normothermic trauma group (IL-8, 12.8 ± 4.7). Accordingly, granulocyte infiltration and a histologic, semiquantitative score for liver injury were significantly higher in the normothermic trauma group. Serum AST levels raised significantly after trauma and normothermia compared with the respective sham group, while AST levels showed no difference from the sham groups in the hypothermic trauma group. In contrast, neither trauma nor hypothermia influenced the expression of IL-6 and IL-8 and tissue injury in the kidney. Therapeutic hypothermia seems to attenuate the hepatic inflammatory response and the associated liver injury after severe trauma. Therefore, induced hypothermia might represent a potential therapeutic strategy to avoid posttraumatic organ dysfunction.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa.

PubMed

Chowdhury, Sharfuddin; Nicol, Andrew John; Moydien, Mahammed Riyaad; Navsaria, Pradeep Harkison; Montoya-Pelaez, Luis Felipe

2018-01-01

The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications ( p  = 0.074). Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Development of a Middle-Age and Geriatric Trauma Mortality Risk Score A Tool to Guide Palliative Care Consultations.

PubMed

Konda, Sanjit R; Seymour, Rachel; Manoli, Arthur; Gales, Jordan; Karunakar, Madhav A

2016-11-01

This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

Induced hypothermia does not impair coagulation system in a swine multiple trauma model.

PubMed

Mohr, Juliane; Ruchholtz, Steffen; Hildebrand, Frank; Flohé, Sascha; Frink, Michael; Witte, Ingo; Weuster, Matthias; Fröhlich, Matthias; van Griensven, Martijn; Keibl, Claudia; Mommsen, Philipp

2013-04-01

Accidental hypothermia, acidosis, and coagulopathy represent the lethal triad in severely injured patients. Therapeutic hypothermia however is commonly used in transplantations, cardiac and neurosurgical surgery, or after cardiac arrest. However, the effects of therapeutic hypothermia on the coagulation system following multiple trauma need to be elucidated. In a porcine model of multiple trauma including blunt chest injury, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of therapeutic hypothermia on coagulation was evaluated. A total of 40 pigs were randomly assigned to sham (only anesthesia) or trauma groups receiving either hypothermia or normothermia. Each group consisted of 10 pigs. Analyzed parameters were cell count (red blood cells, platelets), pH, prothrombin time (PT), fibrinogen concentration, and analysis with ROTEM and Multiplate. Trauma and consecutive fluid resuscitation resulted in impaired coagulation parameters (cell count, pH, PT, fibrinogen, ROTEM, and platelet function). During hypothermia, coagulation parameters measured at 37°C, such as PT, fibrinogen, thrombelastometry measurements, and platelet function, showed no significant differences between normothermic and hypothermic animals in both trauma groups. Additional analyses of thrombelastometry at 34°C during hypothermia showed significant differences for clotting time and clot formation time but not for maximum clot firmness. We were not able to detect macroscopic or petechial bleeding in both trauma groups. Based on the results of the present study we suggest that mild hypothermia can be safely performed after stabilization following major trauma. Mild hypothermia has effects on the coagulation system but does not aggravate trauma-induced coagulopathy in our model. Before hypothermic treatment can be performed in the clinical setting, additional experiments with prolonged and deeper hypothermia to exclude detrimental effects are required.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma

PubMed Central

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-01-01

Abstract We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT. Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome. Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients’ time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06–0.75, P = 0.016). Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma. PMID:27631215

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study.

PubMed

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-09-01

We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT.Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome.Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients' time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06-0.75, P = 0.016).Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.

Thoracostomy tubes: A comprehensive review of complications and related topics

PubMed Central

Kwiatt, Michael; Tarbox, Abigail; Seamon, Mark J.; Swaroop, Mamta; Cipolla, James; Allen, Charles; Hallenbeck, Stacinoel; Davido, H. Tracy; Lindsey, David E.; Doraiswamy, Vijay A.; Galwankar, Sagar; Tulman, David; Latchana, Nicholas; Papadimos, Thomas J.; Cook, Charles H.; Stawicki, Stanislaw P.

2014-01-01

Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes. PMID:25024942

Post-traumatic tricuspid insufficiency: a case report.

PubMed

Tütün, Ufuk; Aksöyek, Ayşen; Parlar, Ali Ihsan; Cobanoğlu, Adnan

2011-11-01

Post-traumatic tricuspid insufficiency is a rare complication of chest trauma. An 18-year-old male patient was injured in a bicycle accident from his abdominal and anterior chest wall. The tear on the inferior diaphragmatic surface of the heart was repaired with primary sutures by the attending surgeon. Eighteen years later, he was admitted to the hospital with severe tricuspid regurgitation (3+/4+). During the operation, the valve was determined unsuitable for repair and was replaced with a bioprosthesis. The hemodynamic aberrations relevant to an isolated tricuspid valve injury are very often well-tolerated. Reconstructive surgery may be possible in the early period. In the late cases, repair is sometimes not feasible due to degeneration of the valvular apparatus. Replacement with a biological prosthesis may give the best long-term results in longstanding cases.

Strategic assessment of the availability of pediatric trauma care equipment, technology and supplies in Ghana.

PubMed

Ankomah, James; Stewart, Barclay T; Oppong-Nketia, Victor; Koranteng, Adofo; Gyedu, Adam; Quansah, Robert; Donkor, Peter; Abantanga, Francis; Mock, Charles

2015-11-01

This study aimed to assess the availability of pediatric trauma care items (i.e. equipment, supplies, technology) and factors contributing to deficiencies in Ghana. Ten universal and 9 pediatric-sized items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with administrative, clinical and biomedical engineering staff were used to assess item availability at 40 purposively sampled district, regional and tertiary hospitals in Ghana. Hospital assessments demonstrated marked deficiencies for a number of essential items (e.g. basic airway supplies, chest tubes, blood pressure cuffs, electrolyte determination, portable X-ray). Lack of pediatric-sized items resulting from equipment absence, lack of training, frequent stock-outs and technology breakage were common. Pediatric items were consistently less available than adult-sized items at each hospital level. This study identified several successes and problems with pediatric trauma care item availability in Ghana. Item availability could be improved, both affordably and reliably, by better organization and planning (e.g. regular assessment of demand and inventory, reliable financing for essential trauma care items). In addition, technology items were often broken. Developing local service and biomedical engineering capability was highlighted as a priority to avoid long periods of equipment breakage. Copyright © 2015 Elsevier Inc. All rights reserved.

Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model

PubMed Central

Mommsen, Philipp; Pfeifer, Roman; Mohr, Juliane; Ruchholtz, Steffen; Flohé, Sascha; Fröhlich, Matthias; Keibl, Claudia; Seekamp, Andreas; Witte, Ingo

2015-01-01

Background. The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. Methods. We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. Results. Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. Conclusions. Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia. PMID:26170533

[Injury severity and pattern at the scene. What is the influence of the mechanism of injury?].

PubMed

Frink, M; Zeckey, C; Haasper, C; Krettek, C; Hildebrand, F

2010-05-01

The mechanism of injury is the major cause for trauma team activation and emergency room resuscitation of trauma victims. To date, it remains unclear to what extent the injury mechanism influences injury pattern and severity. A comprehensive systematic literature search based on Medline was carried out. Only a limited number of studies are available which investigated the influence of injury mechanisms on injury patterns and severity. There are no specific mechanisms for traumatic brain and spine injuries. Injuries to the chest and abdomen most frequently resulted from motor vehicle accidents involving passengers sitting on the side of the impact. Steering wheel deformity correlated with the injury severity. Pelvic fractures occurred most frequently due to motor vehicle accidents. The highest mortality resulted from pedestrians being struck by a vehicle and additional loss of life in the same vehicle compartment. The systematic literature research showed inconsistent results regarding the influence of trauma mechanisms on the resulting injury. Therefore, a treatment algorithm for trauma patients should be independent of the mechanism which is represented in several training programs (e.g. ATLS and PHTLS). However, the mechanism of injury may increase the alertness of the trauma team with respect to injury distribution and severity.

Strategic assessment of the availability of pediatric trauma care equipment, technology and supplies in Ghana

PubMed Central

Ankomah, James; Stewart, Barclay T; Oppong-Nketia, Victor; Koranteng, Adofo; Gyedu, Adam; Quansah, Robert; Donkor, Peter; Abantanga, Francis; Mock, Charles

2015-01-01

Background This study aimed to assess the availability of pediatric trauma care items (i.e. equipment, supplies, technology) and factors contributing to deficiencies in Ghana. Methods Ten universal and 9 pediatric-sized items were selected from the World Health Organization’s Guidelines for Essential Trauma Care. Direct inspection and structured interviews with administrative, clinical and biomedical engineering staff were used to assess item availability at 40 purposively sampled district, regional and tertiary hospitals in Ghana. Results Hospital assessments demonstrated marked deficiencies for a number of essential items (e.g. basic airway supplies, chest tubes, blood pressure cuffs, electrolyte determination, portable Xray). Lack of pediatric-sized items resulting from equipment absence, lack of training, frequent stock-outs and technology breakage were common. Pediatric items were consistently less available than adult-sized items at each hospital level. Conclusion This study identified several successes and problems with pediatric trauma care item availability in Ghana. Item availability could be improved, both affordably and reliably, by better organization and planning (e.g. regular assessment of demand and inventory, reliable financing for essential trauma care items). In addition, technology items were often broken. Developing local service and biomedical engineering capability was highlighted as a priority to avoid long periods of equipment breakage. PMID:25841284