Occult pneumothorax in patients with blunt chest trauma: key findings on supine chest radiography.

Background: In patients with multiple trauma, a supine chest radiography [chest X-ray (CXR)] is preferred over a erect CXR. However, this method has limitations in detecting post-traumatic pneumothorax. The use of chest computed tomography (CT) to detect traumatic pneumothorax is well known. However, pneumothorax that is not detected before a chest CT scan is known as an occult pneumothorax (OP), and it can cause serious complications in the patient. This study sought to evaluate the frequency and risk factors for OP in trauma patients. Methods: Patients who suffered thoracic trauma at the Level 1 Regional Trauma Center of Wonju Severance Christian Hospital between 2015 and 2022 were included in this study. All patients were at least 18 years old. The study reviewed all patients' supine CXR and chest CT images and classified them into five radiographic diagnoses: pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum. Results: The study included 1,284 patients, all with diagnoses of pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum following supine CXR and chest CT. The patient's average age was 58.3±15.2 years. Pneumothorax diagnosis on supine CXR had the lowest accuracy, at 46.7%, and the lowest sensitivity, at 12.7%. In univariate analysis, rib fracture, lung contusion, and subcutaneous emphysema on supine CXR were all found to be statistically significant regarding traumatic OP. In multivariate analysis, the risk factors for OP were lung contusion [odds ratio (OR), 1.440; 95% confidence interval (CI): 1.115-1.860; P=0.005] and subcutaneous emphysema (OR, 25.883; 95% CI: 13.155-50.928; P<0.001) on supine CXR. Conclusions: The lung contusion and subcutaneous emphysema in supine CXR of trauma patients indicate the presence of OP. Therefore, if chest CT cannot be performed immediately due to unstable vital signs or other circumstances, recognizing the above radiological findings of traumatic pneumothorax may be necessary.

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

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

Effect of Antithrombin III Administration on the Prognosis of Severe Trauma Patients with Disseminated Intravascular Coagulation.

BACKGROUND: We aimed to investigate the effects of antithrombin III administration on the prognosis of severe trauma patients with disseminated intravascular coagulation (DIC). METHODS: Medical records of a total of 4023 patients who were admitted to the intensive care unit (ICU) at the single regional trauma center from January 2016 to December 2020 were retrospectively analyzed. After the exclusion of young patients (<15 years old), mild trauma (ISS < 16), non DIC, etc., a total of 140 patients were included in the study. These patients were classified into antithrombin III-administered and non-antithrombin III-administered groups. Clinical data, including laboratory findings, trauma- and ICU-related severity scores, prognosis (including length of hospital stay), and need for organ support, were retrospectively collected. We evaluated the characteristics of the two groups, and compared and analyzed the vital signs, laboratory findings, prognosis, and clinical outcomes of each group. With this, we analyzed the effect of antithrombin III administration in severe trauma patients with DIC. RESULTS: Of the 140 patients, 61 were treated with antithrombin III. No significant difference was observed in the baseline characteristics between the two groups for initial laboratory results, initial vital signs, or trauma-related severity scores. The improvement of the sequential organ failure assessment (SOFA) score, a prognostic marker, was significantly greater in the administered group (p = 0.009). Additionally, the antithrombin-administered group showed a larger improvement in the SOFA score than the non-administered group (p = 0.002). However, there was no statistical difference between the two groups for the frequency or duration of organ support treatments (renal replacement therapy, mechanical ventilation), mortality, or length of hospital stay. CONCLUSION: Antithrombin III administration in severe trauma patients with DIC improved SOFA scores and aided in multi-organ dysfunction recovery. Appropriate indications should be studied to maximize the drug's improvement effect in patients with severe trauma in the future.

Adjuvant intravenous immunoglobulin administration on postoperative critically ill patients with secondary peritonitis: a retrospective study.

BACKGROUND: The use of intravenous immunoglobulin (IVIG) in sepsis patients from bowel perforation is still debatable. However, few studies have evaluated the effect of IVIG as an adjuvant therapy after source control. This study aimed to analyze the effect of IVIG in critically ill patients who underwent surgery due to secondary peritonitis. METHODS: In total, 646 medical records of surgical patients who were treated for secondary peritonitis were retrospectively analyzed. IVIG use, initial clinical data, and changes in Sequential Organ Failure Assessment (SOFA) score over the 7-day admission in the intensive care unit for sepsis check, base excess, and delta neutrophil index (DNI) were analyzed. Mortalities and periodic profiles were assessed. Propensity scoring matching as comparative analysis was performed in the IVIG group and non-IVIG group. RESULTS: General characteristics were not different between the two groups. The survival curve did not show a significantly reduced mortality in the IVIG. Moreover, the IVIG group did not have a lower risk ratio for mortality than the non-IVIG group. However, when the DNI were compared during the first 7 days, the reduction rate in the IVIG group was statistically faster than in the non-IVIG group (P<0.01). CONCLUSIONS: The use of IVIG was significantly associated with faster decrease in DNI which means faster reduction of inflammation. Since the immune system is rapidly activated, the additional use of IVIG after source control surgery in abdominal sepsis patients, especially those with immunocompromised patients can be considered. However, furthermore clinical studies are needed.

Outcomes improvement despite continuous visits of severely injured patients during the COVID-19 outbreak: experience at a regional trauma centre in South Korea.

BACKGROUND: Understanding the changes in characteristics of patients who visited trauma centres during the coronavirus disease 2019 (COVID-19) pandemic is important to facilitate aneffective response. This retrospective study was conducted to analyse differences in the characteristics and outcomes of patients who visited our trauma centre between pre-COVID-19 and COVID-19 eras. METHODS: Medical data of trauma patients enrolled in the Korean trauma database from 1 January 2018 to 31 August 2021 were collected. The number of trauma centre visits, patient characteristics, factors associated with in-hospital intervention, and outcomes werecompared between patients in the two time periods. Propensity score matching was performed to analyse the outcomes in patients with similar characteristics and severitybetween patients in the two time periods. RESULTS: The number of emergency department (ED) trauma service visits reduced in the COVID-19 era. Based on the mean age, the patients were older in the COVID-19 era. Abbreviated injury scale (AIS) 1, AIS3, AIS5, and injury severity score (ISS) were higher in the COVID-19 era. The proportion of motor vehicle collisions decreased, whereas falls increased during the COVID-19 era. Ambulance transportation, admission to the general ward, and time from injury to ED visit significantly increased. Patient outcomes, such as hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of mechanical ventilation improved, while injury severity worsened during the COVID-19 era. After adjusting for patient characteristics and severity, similar findings were observed. CONCLUSION: The small reduction in the number of trauma patients and visits by patients who hadhigher ISS during the COVID-19 pandemic highlights the importance of maintaining trauma service capacity and capability during the pandemic. A nationwide or nationalmulticentre study will be more meaningful to examine the impact of the COVID-19 outbreak on the changes in trauma patterns, volume, and patient outcomes.

Determination of risk factors associated with surgical site infection in patients undergoing preperitoneal pelvic packing for unstable pelvic fracture.

BACKGROUND: Several recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients. METHODS: We retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study. RESULTS: SSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis. CONCLUSIONS: Repacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.

Correlation between the Injury Site and Trauma Mechanism in Severely Injured Patients with Blunt Trauma.

Background: In patients with severe injury, predicting the injury site without using advanced diagnostic modalities can help formulate a diagnosis and treatment plan based on the suspected injury site. Objectives: This study aimed to determine the correlation between the injury site and trauma mechanism in severely injured patients with blunt trauma. Methods: We retrospectively analyzed the clinical characteristics-including age, sex, date of emergency room (ER) visit, time of injury, trauma mechanism (car accident, motorcycle accident, bicycle accident, pedestrian accident, fall, slipping and rolling down, crush injury, assault, and others), final diagnosis, injury severity score, abbreviated injury scale (AIS) score, and injury site-of 1,245 patients in a tertiary trauma center. Results: There was a strong correlation between certain injury sites and specific trauma mechanisms. In particular, most trauma mechanisms were associated with injury to the head and neck, as well as the chest, with a combined frequency of >40.0%. Moreover, when using one-way analysis of variance and Bonferroni's post hoc tests, there were significant differences in AIS scores 1, 3, 4, and 5 for each trauma mechanism. Conclusion: Generally, when patients with severe injury present to the ER, the injury site can be predicted upon initial assessment based on the trauma mechanism. Based on our study, the injury site predicted by a specific mechanism should be checked repeatedly and additionally through physical examination and imaging tools. This can reduce misdiagnosis and help with accurate diagnosis and treatment.

The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study.

PURPOSE: Recently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the "no zone" approach in traumatic neck injuries. METHODS: Medical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the "zone" and/or no zone approach. RESULTS: Out of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55-157.60). CONCLUSION: Traumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.

Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis.

INTRODUCTION: We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures. MATERIALS AND METHODS: Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients. RESULTS: As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively). CONCLUSIONS: The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.

Delta neutrophil index for predicting mortality in trauma patients who underwent emergent abdominal surgery: A case controlled study.

BACKGROUND: Delta neutrophil index (DNI) can be used as a biomarker for infection to predict patient outcomes. We aimed to investigate the relationship between DNI and clinical outcomes in trauma patients who underwent abdominal surgery. MATERIALS AND METHODS: We retrospectively analyzed injured patients who underwent emergent abdominal surgery in the regional trauma center of Wonju Severance Christian Hospital between March 2016 and May 2018. Patient characteristics, operation type, preoperative and postoperative laboratory findings, and clinical outcomes were evaluated. Logistic regression analysis was performed for risk factors associated with mortality. RESULTS: Overall, 169 patients (mean age, 53.8 years; 66.3% male) were enrolled in this study, of which 19 (11.2%) died. The median injury severity score (ISS) was 12. The non-survivors had a significantly higher ISS [25(9-50) vs. 10(1-50), p<0.001] and serum lactate level (9.00±4.10 vs. 3.04±2.23, p<0.001) and more frequent shock (63.2% vs 23.3%, p<0.001) and solid organ injury (52.6% vs. 25.3%, p = 0.013) than the survivors. There were significant differences in postoperative DNI between the two groups (p<0.009 immediate post-operation, p = 0.001 on postoperative day 1 [POD1], and p = 0.013 on POD2). Logistic regression analysis showed that the independent factors associated with mortality were postoperative lactate level (odds ratio [OR] 1.926, 95% confidence interval [CI] 1.101-3.089, p = 0.007), postoperative sequential organ failure assessment score (OR 1.593, 95% CI 1.160-2.187, p = 0.004), and DNI on POD1 (OR 1.118, 95% CI 1.028-1.215, p = 0.009). The receiver operating characteristics curve demonstrated that the area under the curve of DNI on POD1 was 0.887 (cut-off level: 7.1%, sensitivity 85.7%, and specificity 84.4%). CONCLUSIONS: Postoperative DNI may be a useful biomarker to predict mortality in trauma patients who underwent emergent abdominal surgery.

Experiences of the Emergency Department at the Pyeongchang Polyclinic During the 2018 PyeongChang Winter Olympic Games.

PURPOSE: The 2018 PyeongChang Winter Olympic Games involved 2925 elite athletes, and providing proper health care services for these elite athletes was a critical priority. We established an emergency department (ED) in the Pyeongchang Mountain Polyclinic during the Olympics, which served staff and athletes from many countries. This experience, as well as a description of illnesses and injuries encountered during the games, may provide useful information for planning medical care at similar events in the future. MATERIALS AND METHODS: The polyclinic ED operated from January 25 to February 27, 2018. All cases were enrolled in this study, and their data were analyzed by date and category. In addition, the number of injuries by body part, number of illnesses by organ system, and illness symptoms and causes were analyzed. RESULTS: In total, 288 patients were encountered in the ED. These included 113 injuries and 175 illnesses. We consulted with 153 staff members and 75 athletes, and reported that the fingers were the most commonly injured body part, followed by the knee. The respiratory system was the most commonly involved organ system, and the most common cause of illness was infection. Thirty-eight influenza tests were performed, among which the results of seven were positive. We performed 17 norovirus tests, among which the results of four were positive. CONCLUSION: Our analysis of our ED experience will aid arrangements for medical services in future Winter Games. Additionally, given our new experience, we will now be able to provide better medical services for future winter sports events.

Clinical characteristics of primary epiploic appendagitis.

PURPOSE: Primary epiploic appendagitis (PEA) is a rare cause of an acute abdomen. It can be clinically misdiagnosed as either diverticulitis or appendicitis on clinical examination because the clinical symptoms and signs of PEA are non-specific. The present study was performed to describe the clinical characteristics of PEA and to assess the differences between PEA and diverticulitis. METHODS: We reviewed the clinical records and radiologic findings of 31 consecutive patients with PEA and compared them with those of patients with diverticulitis without complications. RESULTS: In most cases, abdominal pain was localized to the right (13 cases, 41.9%) or left (13 cases, 41.9%) lower quadrants. Gastrointestinal symptoms such as nausea and vomiting were infrequent, and localized tenderness without peritoneal irritation was common. All patients were afebrile, and only 4 patients (12.9%) showed leukocytosis. In all cases except one, a pericolic fatty mass with a hyperattenuated ring was observed on computed tomography. Patients with left PEA were younger than those with diverticulitis (41.4 ± 11.9 vs. 69.7 ± 13.3, P < 0.001), and the mean body mass index was higher in patients with left PEA (26.4 ± 2.9 vs. 22.6 ± 3.4, P = 0.01). Whereas one patient (6.7%) with left PEA showed leukocytosis, the incidence of leukocytosis in patients with diverticulitis was 80% (8/10) (P < 0.001). CONCLUSION: In patients with an acute abdomen showing localized tenderness without associated symptoms or leukocytosis, a high index of suspicion for PEA is necessary. For correct diagnosis and proper management, it would useful for surgeons to be aware of the computed tomographic findings and the natural course of the disease.